Ethnic and seasonal variations in FGF-23 and markers of chronic kidney disease-mineral and bone disorder.

Background: Fibroblast growth factor 23 (FGF-23) and other markers of chronic kidney disease-mineral and bone disorder (CKD-MBD) provide valuable insights into disease processes, treatment options and patient prognosis. However, limited research has explored potential associations with ethnicity or season, particularly in multi-ethnic populations residing in high-latitude regions. Methods: We evaluated CKD-BMD markers in a diverse cohort of CKD patients, who were participants of The CANADIAN AIM to PREVENT (the CAN AIM to PREVENT) study. FGF-23, calcium, phosphate, 25-hydroxyvitamin D (25-OHD) and intact parathyroid hormone (iPTH) in 1234 participants with pre-dialysis CKD (mean estimated glomerular filtration rate: 41.8 ± 14.3 mL/min) were analyzed. Mixed-effects general linear regression models adjusted for demographic and biological factors were used to compare repeated measurements across patient groups categorized by ethnicity (East Asian, White, South Asian, Black, Southeast Asian) and seasons. Results: Compared with other groups, White participants exhibited 8.0%-18.5% higher FGF-23 levels, Black participants had 0.17-0.32 mg/dL higher calcium levels, White participants had 10.0%-20.1% higher 25-OHD levels, South Asian participants had 7.3%-20.1% lower 25-OHD levels and Black participants had 22.1-73.8% higher iPTH levels, while East Asian participants had 10.7%-73.8% lower iPTH levels. Seasonal variations were also observed. FGF-23 levels were 11.9%-15.5% higher in summer compared with other seasons, while calcium levels were 0.03-0.06 mg/dL lower in summer. 25-OHD levels were 5.6%-10.6% higher in summer and autumn compared with other seasons. Conclusions: This study shows that FGF-23 and CKD-MBD markers in a Canadian pre-dialysis CKD cohort vary independently by ethnicity and season. Further research is needed to understand the reasons and clinical significance of these findings.

Serum fetuin-A levels, QT dispersion and P dispersion in dialysis patients.

BACKGROUND: This study aims to find association of fetuin-A with serum lipids, QT dispersion (QT-d), and P dispersion (P-d) in dialysis patients. METHODS: Fetuin-A serum levels were assessed in 50 dialysis patients. RESULTS: Serum fetuin-A levels were significantly associated with QT-d (r = 0.289, p = 0.044), P-d (r = 0.39, p = 0.005), total cholesterol (r = 0.526, p = 0.000), low-density lipoprotein cholesterol (LDL-C) (r = 0.456, p = 0.00), triglyceride (r = 0.360, p = 0.011) and highly sensitive C-reactive protein (hsCRP) (r = -0.347, p = 0.030). In step-wise multiple regression analysis including being on hemodialysis (HD), presence of diabetes mellitus (DM), total cholesterol, LDL-C, triglycerides, hsCRP, only total cholesterol (b = 0.419, p = 0.03), and hsCRP (b = -0.316, p = 0.03) proved to be independent predictors of serum fetuin-A levels. QT-d showed a linear correlation with total cholesterol (r = 0.309, p = 0.029), LDL-C (r = 0.304, p = 0.038), P-d (r = 0.390, p = 0.005), and fetuin-A levels (r = 0.289, p = 0.044). In multiple regression analyses, the independent predictor of QT-d was being on HD (b = -0.417, p = 0.004), whereas total cholesterol, LDL-C, presence of DM, serum fetuin-A levels, and P-d had no independent effect on corrected QT (QT-C). Being on HD and age were important determinants of P-d whereas presence of DM, total cholesterol, LDL-C, fetuin-A, and QT-d had no independent effect on P-d. CONCLUSIONS: Lower fetuin-A levels are associated with high hsCRP and low cholesterol levels in dialysis patients.

NGAL and NT-proBNP levels in diabetic patients with macroproteinuria.

BACKGROUND: In patients with heart failure plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) levels are correlated to urine neutrophil gelatinase-associated lipocalin (NGAL) levels. We prospectively evaluated the relationship among glomerular filtration rate (eGFR), urine albumin-to-creatinine ratio (ACR), urine and serum NGAL and NT-proBNP levels in 20 type II diabetic patients with macroalbuminuria at 4-month intervals. RESULTS: Compared with 20 age, gender-matched healthy controls, diabetic patients had higher urine and serum NGAL, serum NT-proBNP and lower eGFR. The eGFR of the patients at the baseline, the 4th and the 8th month were 29.6 ± 12.0, 27.8 ± 13.7 and 22.9 ± 10.4 mL/min/1.73 m(2), respectively. No significant change in urine NGAL levels was detected (p > 0.05), whereas there were significant increases in NT-proBNP, serum NGAL and urine ACR and significant decrease in eGFR as the study progressed (p < 0.05). Both the baseline and the 4th month urine ACR were positively correlated to NT-proBNP levels measured at the same periods (r: 0.451; p: 0.046; r: 0.489; p: 0.029 respectively). In all measurements, urine ACR was negatively correlated to serum albumin levels measured at the same periods (r: -0.792; p: 0.000; r: -0.716; p: 0.000; r: -0.531; p: 0.016 respectively). None of eGFR measurements was correlated with NT-proBNP (p > 0.05). Neither serum NGAL nor urinary NGAL levels are associated with NT-proBNP (p > 0.05). CONCLUSION: Our findings show an association between NT-proBNP and proteinuria in type II diabetic patients with macroalbuminuria but not with serum and urine NGAL.

Functional patency rates of arteriovenous fistula of a retrospective cohort study from one of the biggest centers in Canada.

BACKGROUND: The main barriers to arterio-venous fistula (AVF) utilization are primary failure, long maturation duration, and low secondary patency rates. METHODS: In this retrospective cohort study, primary, secondary, functional primary, and functional secondary patency rates were calculated and compared between two age groups (< 75 years and > = 75 years) and between radiocephalic (RC-) and upper arm (UA-) AVFs, and factors determining the duration of functional secondary patency were evaluated. RESULTS: Between 2016 and 2020, 206 predialysis patients whose AVFs had been created previously initiated renal replacement treatment. RC-AVFs comprised 23.3% and were created after favorable analysis of the forearm vasculature. Overall, the primary failure rate was 8.3, and 84.7% started hemodialysis with a functioning AVF. Functional secondary patency rates of primary AVFs were better with RC-AVFs [1,3 and 5 year rates of 95.8, 81.9 and 81.9% versus 83.4, 71.8 and 59.2% for UA-AVFs (log rank p: 0.041)]. There was no difference between the two age groups for any of the AVF outcomes assessed. Among patients whose AVF was abandoned, 40.3% had gone on to have a second fistula created. This was significantly less likely in the older group (p < 0.01). IN CONCLUSION: (1) UA-AVFs were placed more commonly than RC-AVFs; (2) a selection bias existed whereby RC-AVFs were only created after favorable forearm vasculature was demonstrated or suspected; (3) superior functional secondary patency rates were observed with RC-AV's, perhaps stemming from this selection bias; (4) the elderly were more likely to have only one AVF creation attempt.

QTc interval prolongation independently associates with FGF23 and predicts mortality in predialysis CKD.

INTRODUCTION: QTc interval prolongation is increasingly frequent as CKD advances and predicts death in dialysis. However, predictors and mortality-risk in predialysis CKD are understudied. FGF23 induces left ventricular hypertrophy (LVH) which is associated with QTc interval prolongation and death, suggesting a possible pathway from FGF23 to death that entails LVH and QTc prolongation. We looked for links between FGF23 and prolonged QTc intervals mediated by LVH, and for deaths associated with QTc prolongation in a prospective observational cohort of patients with predialysis CKD. METHODS: Participants underwent protocolized baseline and semi-annual FGF23 testing, baseline and study end echocardiograms, and baseline and annual electrocardiograms over three years. RESULTS: 2,254 participants (34.1% female; mean age 68.7 years; mean glomerular filtration rate 41.4 ml/min/m2) enrolled. Baseline LVH (left ventricular mass index >131 g/m2 (>100 g/m2 if female)) was present in 10.8% and prolonged QTc intervals (>=500 ms) in 1.5%. One hundred thirty-eight (6.1%) participants died during the study. In generalized mixed effects regression, each unit increase in the natural log of FGF23 - but not LVH - predicted an odds ratio of 1.76 (1.15, 2.70, p=0.009) for prolonged QTc intervals independently of 15 other covariates. Mediation analysis showed that only 13% of FGF23's total effect on prolonged QTc intervals was mediated by LVH. Patients with prolonged QTc intervals had higher unadjusted (log rank p<0.001) and adjusted (hazard ratio 3.15 (1.38, 7.16, p=0.006)) mortality rates than those with QTc intervals <500 ms. CONCLUSIONS: QTc interval prolongation ≥500 ms was prospectively associated with FGF23 independently of LVH, and with a tripling of mortality-risk in patients with predialysis CKD.

Mortality after kidney transplantation: 10-year outcomes.

OBJECTIVES: In the past decade, advances in immunological therapy have increased the survival of kidney recipients and their grafts. However, it has not achieved the desired level of improvement. This study aims to reveal the mortality among kidney recipients. METHODS: Medical data of the patients, who had undergone kidney transplantation (KT) between November 2010 and December 2020, were retrospectively reviewed. Inclusion criteria were adult kidney recipients, who had died. Exclusion criteria were pediatric recipients, recipients of en bloc and dual KT, recipients with missing data, and recipients with a primary non-functioning graft. The recipients were grouped according to their donor type; Group 1 (from a living donor) and Group 2 (from a deceased donor). Subgroup analyses were done for mortality by time-period post-transplant and for infectious causes of mortality. RESULTS: Of 314 recipients, 35 (11.14%) died. Twenty-nine recipients were included in the study (Group 1: 17 and Group 2: 12). The most common cause of mortality was infection (58.6%), and the second was cardiovascular disease (CVD) (24.1%). Sepsis developed in 29.4% of infection-related deaths, while COVID-19 constituted 23.5% of infection-related deaths. CONCLUSION: Early diagnosis and treatment of infectious and CVD are important to improve survival in kidney recipients.

OBJETIVOS: En la última década, los avances en la terapia inmunológica han aumentado la supervivencia de los receptores de riñón y sus injertos. Sin embargo, no se pudo lograr el nivel de mejora deseado. Este estudio tiene como objetivo revelar la mortalidad entre los receptores de riñón. MATERIALES Y MÉTODOS: Se revisaron retrospectivamente los datos médicos de los pacientes, que se habían sometido a un trasplante de riñón entre Noviembre de 2010 y Diciembre de 2020. Los criterios de inclusión fueron los receptores de riñón adultos, que habían fallecido. Los criterios de exclusión fueron los receptores pediátricos, los receptores de trasplantes de riñón dual y en bloque, los receptores con datos faltantes y los receptores con un injerto primario no funcionante. Los receptores se agruparon según su tipo de donante; Grupo 1 (de un donante vivo) y Grupo 2 (de un donante fallecido). Se realizaron análisis de subgrupos para la mortalidad por período de tiempo posterior al trasplante y para las causas infecciosas de mortalidad. RESULTADOS: De 314 beneficiarios, 35 (11,14%) fallecieron. Se incluyeron 29 receptores en el estudio (Grupo 1:17; Grupo 2:12). La causa más común de mortalidad fue la infección (58,6%) y la segunda fue la enfermedad cardiovascular (24,1%). La sepsis se desarrolló en el 29,4% de las muertes relacionadas con la infección, mientras que el COVID-19 constituyó el 23,5% de las muertes relacionadas con la infección. CONCLUSIÓN: El diagnóstico y tratamiento tempranos de enfermedades infecciosas y cardiovasculares es importante para mejorar la supervivencia de los receptores de riñón.

Transplantation Using Renal Grafts With Multiple Renal Arteries: A Putative Study on the Impact of Arterial Reconstruction Technique and Site of Implantation on Outcomes.

BACKGROUND: In the present retrospective study, we analyzed the outcomes of patients transplanted with grafts with multiple renal arteries (MRAs). PATIENTS AND METHODS: In total, 89 patients were transplanted with renal grafts with MRAs from 2003 to 2018. Demographic characteristics; type of donor; warm and cold ischemia times; arterial anastomosis technique; complications; graft function at first month, first year, and last outpatient clinic visit; and patient and graft survival were all retrospectively evaluated. RESULTS: The mean age of the patients was 40.4 ± 13.3 years. Fifty-six patients (62.9%) were male. In total, 42 patients (47.2%) received renal grafts from living related donors. In group A (n = 24; 27%), anastomosis was performed separately to the recipient external or internal iliac arteries; in group B (n = 38; 42.7%), the secondary artery was anastomosed to the main artery in a side-to-side fashion to form a single common orifice; in group C (n = 27; 30.3%), secondary arteries were anastomosed to the main renal artery in an end-to-side fashion. Creatinine clearance at the first month was significantly lower for deceased-donor grafts compared to living-donor renal grafts (P < .05). Creatinine clearance in the first postoperative month was significantly lower in group A and creatinine clearance in the first year was significantly lower in group C (P < .05). The best survival was found for anastomosis to the internal iliac artery (P < .05). CONCLUSION: MRAs can be safely used and the reconstruction technique does not matter if the graft kidney's arterial supply is preserved and the internal iliac artery is chosen for anastomosis.

Mucormycosis Presented with Facial Pain in a Renal Transplant Patient: A Case Report.

INTRODUCTION: Mucormycosis is a severe infection in renal transplant recipients. Here, we report a case of maxillary sinus mucormycosis in a patient who presented with a facial pain complaint. CASE: A 51-year-old female patient with renal transplantation due to autosomal dominant, polycystic kidney disease and diabetic nephropathy was admitted to our hospital with facial pain and minimal edema of the left half of her face on the 8th month of transplantation. On physical examination, there was only tenderness and slight edema on the left half of the face. On the paranasal computed tomography, extensive soft tissue densities involving septations, filling the left maxillary sinus, extending to the nasal cavity, and obliterating the left osteometeal unit were observed. Because facial pain was not relieved by antibiotics and several, potent analgesic drugs on the second day, mucormycosis infection with bone involvement was suspected. A left maxillary sinus excision was performed. Microscopic examination of the debridement specimen revealed necrotic bone interspersed with fungal hyphae, and culture isolated Rhizopus oryzae. Liposomal amphotericin B was started. The patient was on tacrolimus, prednisolone, and mycophenolate mofetil. Tacrolimus was switched to cyclosporine to regulate serum glucose levels. The left maxillary sinus was washed with liposomal amphoterin B daily and curetted with intervals. The patient started dialysis because of severe renal function loss. The patient was discharged on the 96th day of liposomal amphotericin B. CONCLUSION: It should be kept in mind that mucormycosis may be present in the sinuses even if there is no evidence for nasal, oral, and dental examination in renal transplant patients with facial pain.

Factors Affecting eGFR Slope of Renal Transplant Patients During the First 2 Years.

PURPOSE: In healthy individuals, glomerular filtration rate decreases by 1 mL/min/y after a peak level of 125.0 mL/min has been reached in adulthood. Any reduction greater than this is a progressive slope (slope more negative than -1 mL/min/y, stable [-1 to +1]), or an improvable slope if it shows more of an increase, that is, greater than +1.0 mL/min/y). The aim of the study was to determine the factors affecting estimated glomerular filtration rate (eGFR) slope during the first 2 years of renal transplant in patients with negative pretransplant panel-reactive antibody. MATERIALS AND METHODS: The characteristics of 59 renal transplant patients, such as age, sex, etiology, and 2 years of laboratory data, were collected retrospectively. For each patient, the eGFR decline rate (slope) (mL/min-1/1.73 m2-1/y-1) was determined by linear regression analysis using all calculated eGFR values over the study period. FINDINGS: Of 59 patients, 7 (11.8%) had a progressive slope, 22 (37.2%) had a stable slope, and 30 (50.8%) had an improvable slope. The first-year mean tacrolimus level was lower in patients with progressive slope than in the patients with stable slope and improvable slope (P < .022). The determinants of eGFR slope in multiple regression analysis were post-transplant hypertension (ß = -0.393; P = .002) and the first-year mean tacrolimus level (ß = 0.320; P = .01), whereas age, serum albumin, and 2-year mean tacrolimus level did not reach the level of significance. CONCLUSION: Keeping tacrolimus levels high in the first year to prevent eGFR declining is important.

Unusually prolonged vitamin D intoxication after discontinuation of vitamin D: possible role of primary hyperparathyroidism.

A 77-year-old woman had taken 50,000 IU of vitamin D2 daily, instead of once weekly, for over 2 years. She developed severe hypercalcemia, and after stopping vitamin D, her serum 25-hydroxyvitamin D (25(OH)D) remained higher than 250 nmol/l for almost 2(1/2) years. Inappropriately high parathyroid (PTH) concentrations were particularly evident after serum calcium was suppressed to slightly above the reference range by the administration of intravenous pamidronate and prednisone. It seems that an underlying primary hyperparathyroidism that was masked initially by the hypercalcemia of vitamin D intoxication was responsible for the unusually prolonged half-life of 25(OH)D in the blood. After vitamin D2 had been stopped, the decline in serum 25(OH)D was unusually slow. In this unusual case, primary hyperparathyroidism probably prevented an appropriate increase in the vitamin D-catabolizing enzyme, 25(OH)D-24-hydroxylase, thereby slowing metabolic clearance of 25(OH) vitamin D.

Improvement in eGFR in patients with chronic kidney disease attending a nephrology clinic.

BACKGROUND: The adverse effects arising from late referral to a nephrologist of patients with chronic kidney disease (CKD) are well known. Retrospectively we examined the initial characteristics of patients referred in various stages of CKD to our nephrology division and tried to identify potential baseline factors associated with subsequent changes in estimated glomerular filtration rate (eGFR). PATIENTS AND METHODS: Between September 1997 and June 2006 1,443 patients (909 male, 534 female) with CKD, with eGFRs ranging from 15 to 89 ml/min, were referred to our nephrology division and categorized using the National Kidney Foundation classification for CKD based on eGFR. The slope of eGFR change (ml/min-1/1.73/m2-1/year-1) was determined by linear regression analysis and the patients were divided into five groups: (1) significantly progressive slope (deterioration) (more negative than -5 ml/min/year); (2) mildly progressive slope (>-5 to -1 to +1 to or=+5). RESULTS: At the first nephrology referral, 5.8% of the patients were on CKD stage 2 (eGFR: 90-60 ml/m), 46.7% on CKD stage 3 (eGFR: 59-30 ml/m), and 47.5% on CKD stage 4 (eGFR: 29-15 ml/m) CKD. Significantly improved slope was detected in 48.2% of CKD stage 2 patients, 29.3% of CKD stage 3 patients, and only 14.7% of CKD stage 4 patients (P<0.05). Being in stage 4 or stage 3 versus being in stage 2 significantly reduced the likelihood of an improved slope in logistic regression analysis whereas age, gender, presence of hypertension, and diabetes mellitus did not reach the level of significance. CONCLUSION: Referral to a nephrology clinic can lead not only to arrest of progression of CKD but also to regression/improvement. Early referral is a positive predictive factor for improvement in eGFR, which emphasizes the importance of such referral. The previously held idea that, once established, CKD progresses invariably is not valid anymore.

Management of non-vascular complications following renal transplantation using percutaneous approach.

OBJECTIVE: Non-vascular complications following renal transplantation can cause graft failure. In this study, we present our two-year experience with percutaneous treatment for non-vascular complications following renal transplantation. PATIENTS AND METHODS: A total of 30 patients who underwent percutaneous radiological treatment between March 2014 and July 2016 were included in the study. RESULTS: Following renal transplantation, a total of 36 percutaneous radiological procedures which includes hydronephrosis secondary to ureteral stricture (n. 15), clinical symptom-producing lymphocele due to pressure (14) and creatinine elevated nondilated grafts (n. 7) after excluding other reasons of creatinine elevation, were performed. Six patients received percutaneous treatment for both ureteral stricture and lymphocele. The patients underwent balloon dilatation and double- J ureteral stent due to ureteral stricture. The mean pre- and post-procedural creatinine levels were 4.36 ± 2.84mg/dL and 2.17 ± 1.24 mg/dL respectively (p=0.004), indicating a significant difference. For lymphocele treatment, sclerosing agents were injected and lymphatic leakage areas were injected with percutaneous glue. The mean pre- and post-procedural creatinine values were 2.97 ± 1.78 mg/dL and 1.75 ± 1.18 respectively (p=0.002), indicating a significant difference. Nephrostomy catheters were placed for patients with elevated creatinine levels and non-dilated collecting system. The mean pre- and post- nephrostomy creatinine levels were 3.55 ± 2.36 mg/dL and 2.57 ± 1.82 mg/dL respectively (p>0.05), indicating no statistically significant difference. CONCLUSION: The results of our study suggest that percutaneous treatment is an effective method for the treatment of non-vascular complications following renal transplantation, and, therefore, should be the first option for the preservation of graft functions. KEY WORDS: Percutaneous treatment, Renal transplantation.

A Novel Technique in the Treatment of Lymphoceles After Renal Transplantation: C-Arm Cone Beam CT-Guided Percutaneous Embolization of Lymphatic Leakage After Lymphangiography.

BACKGROUND: We aimed to evaluate the efficacy of percutaneous embolization after lymphangiography using C-arm cone-beam computed tomography (CBCT) performed at the site of lymphatic leakage in patients with postrenal transplant lymphocele. METHODS: Between July 2014 and August 2017, 13 patients not responding to percutaneous ethanol sclerotherapy and conservative treatment for recurrent lymphocele after renal transplant were included. The mean age of the patients was 56.38 ± 9.91 (range, 36-70) years, and it comprised 9 men and 4 women. All patients underwent intranodal lymphangiography. C-arm CBCT-guided percutaneous embolization was performed in patients with confirmed lymphatic leakage. Patients who had no lymphatic leakage underwent drainage with fibrin glue injection. RESULTS: Lymphatic leakage was observed in 9 patients after lymphangiography, and they underwent CBCT-guided percutaneous N-butyl-2-cyanoacrylate embolization. The volume of lymphatic drainage reduced to less than 10 mL in 8 patients. One patient who was not responding to embolization was treated surgically, after percutaneous drainage and fibrin glue injection. Lymphatic leakage was not observed in 4 patients after lymphangiography. Of these, 3 patients showed a reduction in the amount of lymphatic drainage after lymphangiography. All 4 patients underwent percutaneous drainage and fibrin glue injection. One patient did not respond to the treatment and was treated surgically. Prelymphangiography and postlymphangiography and embolization, the volume of lymphatic drainage was 113.07 ± 21.75 mL, and 53.84 ± 30.96 mL, respectively, and statistically significant decrease was detected (P < 0.005). CONCLUSIONS: Lymphangiography and CBCT-guided percutaneous embolization procedures might be an effective treatment method for patients with lymphocele refractory to treatment.

Brain natriuretic peptide and P wave duration in dialysis patients.

OBJECTIVES: P wave duration and dispersion, defined as the difference between the maximum and minimum P duration, are regarded as very important non-invasive ECG markers for assessing atrial arrhythmia risk. Plasma brain natriuretic peptide (BNP) level is an independent predictor of recurrence of atrial fibrillation. We compared the effects of hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) on P wave duration, P dispersion, and BNP in end-stage renal disease (ESRD) patients and examined the relationship between BNP levels, P wave duration, and P dispersion. DESIGN AND METHODS: Age-matched 22 HD patients (mean age 52.3 +/- 14.0 years) and 19 CAPD patients (mean age 46.7 +/- 10.9 years) were studied. RESULTS: BNP levels were greater in HD patients before the HD session (459.0 +/- 465.1 pg mL(-1)) than in CAPD patients (139.0 +/- 170.1 pg mL(-1)). The maximum and minimum P duration, and P dispersion, were similar for both groups (P > 0.05). Whereas BNP levels were negatively related to minimum P duration (r = -0.518, P = 0.019), BNP levels were positively correlated with systolic blood pressure and diastolic blood pressure (r = 0.672, P = 0.001 and r = 0.497, P = 0.022, respectively) in HD patients. CONCLUSIONS: Whereas BNP levels are higher in HD patients when they are at peak-volume status, just before HD, P wave duration and P dispersion were similar for both groups. A negative relationship was detected between BNP levels and minimum P duration in HD patients. Expansion of extra-cellular volume causing myocardial stretching may be the principal cause of increased BNP in HD patients. A functional relationship between BNP and the P wave was not found. Additional studies are needed to evaluate the effect of BNP on the P wave.

Neutrophil gelatinase-associated lipocalin reflects the severity of anemia without iron deficiency and secondary hyperparathyroidism in hemodialysis patients.

OBJECTIVE: Secondary hyperparathyroidism (SHPT) and anemia are the primary and most common complications in patients receiving hemodialysis (HD). Neutrophil gelatinase-associated lipocalin (NGAL) is a new marker to assess iron deficiency and manage iron therapy for HD patients. The aim of this study was to determine any association between serum NGAL level and anemia without iron deficiency in patients with SHPT on chronic HD. METHODS: Total of 61 SHPT patients on chronic HD were enrolled in the study and divided into 3 groups: mild SHPT group (n=17), moderate SHPT group (n=21), and severe SHPT group (n=23). Hemogram, biochemical assays, and level of ferritin, high sensitivity C-reactive protein (hs-CRP), and NGAL were evaluated in all groups. RESULTS: Serum NGAL level was significantly higher and hemoglobin (Hb) level was significantly lower in severe SHPT patients compared with both mild and moderate SHPT patients. Furthermore, in severe SHPT group, serum NGAL level was significantly positively correlated with serum parathyroid hormone (r=0.79; p=0.00) and hs-CRP (r=0.52; p=0.01) level and negatively correlated with serum Hb (r=-0.56; p=0.00) level. CONCLUSION: SHPT was important factor affecting anemia in HD patients. Even when iron deficiency anemia is excluded in patients with SHPT, there was significant negative correlation between serum NGAL and Hb.

Cephalometric evaluation of patients with Sagliker syndrome: uglifying human face appearance in severe and late secondary hyperparathyroidism in chronic renal failure patients.

It is well known that secondary hyperparathyroidism may be an extremely severe condition in chronic renal failure, and almost all patients with chronic kidney disease, even in the well-developed countries, encounter every kind of bone abnormalities if they are not treated properly. Although some sporadic cases have been reported of unique facial bone changes, the largest collection of this phenomenon has been reported by Sagliker et al. We also have found 6 of 9 patients who have these changes (Sagliker syndrome) to manifest class II malocclusion of the upper and lower jaws according to dental universally accepted criteria by performing cephalometric studies, x-ray plain films, tomographic procedures, and drawing technology.

Neurologic manifestations in Sagliker syndrome: uglifying human face appearance in severe and late secondary hyperparathyroidism in chronic renal failure patients.

Patients with chronic renal failure (CRF) often have signs and symptoms related to fluid and electrolyte disturbances, anemia, malnutrition, bone disease, and gastrointestinal problems. Vascular and neurologic impairment in particular remain an important source of morbidity and mortality in this vulnerable patient population. Sagliker syndrome is a novel syndrome that was recently described in 2004 in patients with CRF and severe and late secondary hyperparathyroidism who suffered from severe skull and facial bone changes, particularly from uglifying human face appearances and neuropsychiatric disorders. The goal of this study was to assess neuropsychiatric manifestations occurring in CRF patients with Sagliker syndrome. Four female and 8 male patients with CRF on regular dialysis at the hemodialysis units of the Internal Medicine Departments around southern Turkey participated in the study. All patients underwent a clinical neurologic examination performed by the same neurologist. Neuropsychiatric signs and symptoms were found in all cases. The results showed that the most frequent neurologic manifestations in CRF patients with Sagliker syndrome were headache, polyneuropathy, cranial neuropathy, fatigue, and psychiatric disorders.

25(OH) vitamin D3 in patients with chronic kidney disease and those on dialysis: rediscovering its importance.

In terms of both exogenous sources (diet), and endogenous production (activation through exposure to ultraviolet light), vitamin D is unique. Few foods naturally contain vitamin D and only a few are fortified with vitamin D. Most people get more than 90% of their vitamin D requirements from exposure to sunlight. Those who protect their skin from ultraviolet-B radiation with clothing or sunscreen, the elderly, and dark-skinned individuals have limited capacity to produce vitamin D. Vitamin D deficiency is common in the general population and even more common in patients with chronic renal failure (CKD). Increased use of sun-blocking agents and decreased exposure to sunlight, to reduce the risk of skin cancer, attributed to exposure to UV radiation, may contribute to the increase in vitamin D deficiency in the population. These issues are particularly important in the dialysis population who are at particular risk because these, mostly elderly, individuals have an inactive life style and have reduced exposure to sunshine and UV light, thus limiting the actinic synthesis of vitamin D. The nephrology community seems to have overlooked the importance of vitamin D for overall health and well being in patients with CKD. Recently however, several authors have called attention to the role of plasma 25(OH)D3 levels in mineral metabolism dysregulation in patients with chronic kidney diseases, and those on dialysis. Vitamin D not only contributes to skeletal health but also plays a major role in the health of a wide variety of other organ systems. It seems that vitamin D supplementation is the most effective way of preventing vitamin D deficiency.

K/DOQI guideline requirements for calcium, phosphate, calcium phosphate product, and parathyroid hormone control in dialysis patients: can we achieve them?

BACKGROUND: Mineral metabolism has emerged as an important predictor of morbidity and mortality in dialysis patients. Kidney Disease Outcomes Quality Initiative (K/DOQI) clinical practice guidelines for bone metabolism and disease in chronic kidney disease (CKD) recommend that, in Stage 5 CKD, the target levels for calcium (Ca) (corrected for serum albumin), phosphate (P), calcium x phosphate (CaxP) product and parathyroid hormone (PTH) levels should be maintained at 8.4-9.5 mg/dl, 3.5-5.5 mg/dl, <55 mg2/dl2 and 150-300 pg/ml, respectively. OBJECTIVES: To evaluate our ability to achieve K/DOQI guidelines for bone metabolism and disease targets in our patients and to compare them between patients on hemodialysis (HD) and peritoneal dialysis (PD) and also with those reported in the literature. METHODS: We reviewed bone metabolism laboratory parameters in 57 HD patients and 69 PD patients, who had been on dialysis for more than 9 months. RESULTS: The percentage of patients whose serum Ca, P, CaxP product and PTH were within K/DOQI recommended target ranges were 46%, 53%, 77% and 28% in HD patients and 52%, 65%, 77% and 23% in PD patients, respectively. There were no significant differences between HD and PD patients in the percentage of all parameters that were within K/DOQI recommended target ranges. The percentage of our HD patients who had Ca, P, and PTH levels within recommended target range was similar to those in previous reports. CONCLUSION: In our unit, the management of bone and mineral metabolism in HD and PD patients is still far short of meeting K/DOQI guidelines. These findings appear similar in HD and PD patients. Our findings resemble those reported in the literature.