Estimation of renal function in patients with eating disorders.

BACKGROUND: Renal function could be evaluated with different equations such as Cockcroft-Gault formula (C-G), Mayo Clinic Quadratic (MAYO) and four MDRD variables. Clinical application of different formulae in conditions with severe energy restriction or in obese subjects is still a matter of investigation. METHOD: Renal function of 55 anorexia nervosa (AN) and 44 bulimia nervosa (BN) patients was evaluated with C-G formula for creatinine clearance calculation, and glomerular filtration rate (GFR) was estimated with MAYO and MDRD equations. RESULTS: BN group was older and had higher weight, body mass index (BMI), body surface area than AN subjects; however, their mean BMI was in the normal range. AN group had better renal function than BN one when it was evaluated with MAYO and MDRD; on the contrary, it was worse when it was calculated with C-G. The results obtained from the three formulae were poorly correlated and Bland-Altman analysis confirmed that the results of the three formulae were not in agreement. DISCUSSION: C-G is inaccurate when it is applied to obese or cachectic subjects. MDRD underestimates renal function in normal-high GFR. MAYO seems to be a good alternative to the other equations leading to correct classification of patients; therefore, it should be used to diagnose eating disorder subjects as renal insufficient.

Risk factors for metabolic syndrome in stable Italian renal transplant patients.

BACKGROUND: The prevalence of metabolic syndrome (MS) in renal transplant recipients (RTR) is still under investigation. METHODS: We performed a cross-sectional study of 107 stable RTR who were diagnosed as having MS defined by the Adult Treatment Panel III of the National Cholesterol Education Program (NCEP-ATP III) criteria. Anthropometric, clinical and biochemical data were collected. RESULTS: Mean age of the patients studied was 55 ± 11 years (72 male, 35 female), dialysis duration before transplantation 30 ± 31 months, time since transplantation 42 ± 13 months. Mean serum creatinine was 1.68 ± 0.64 mg/dl; creatinine clearance by Cockcroft-Gault formula 53 ± 20 ml/min, glomerular filtration rate by 4-variable MDRD formula 48 ± 18 ml/min/1.73 m(2). Thirty-seven patients (34.5%) had MS. The MS patients had higher weight (76 ± 13 vs. 68 ± 12 kg, p = 0.0033), body mass index (BMI) (26 ± 4 vs. 24 ± 3 kg/m(2), p = 0.0025), waist circumference (101 ± 11 vs. 90 ± 11 cm, p < 0.0001), prevalence of BMI >25 k/m(2) (57 vs. 34%, p = 0.0254), prevalence of diabetes mellitus before transplantation (8 vs. 0%, p = 0.0157), glycaemia (104 ± 31 vs. 87 ± 11 mg/dl, p = 0.0002), and triglyceridaemia (225 ± 105 vs. 112 ± 35 mg/dl, p < 0.0001). They also showed lower levels of high-density lipoprotein cholesterol (48 ± 15 vs. 68 ± 17 mg/dl, p < 0.0001). Multiple logistic regression analysis showed that only BMI was independently associated with MS (OR 1.21, 95% CI 1.06-1.37, p = 0.0037). CONCLUSIONS: MS according to NCEP-ATP III criteria appears to be present in about one-third of RTR, and even small increases in BMI above 25 kg/m(2) may determine the presence of MS in these patients. Therefore the preventive value of lifestyle modifications is very important for such patients, in order to strictly maintain body fat accumulation within the normal range.

Cardiorenal syndrome: still not a defined entity.

Because of the increasing incidence of cardiac failure and chronic renal failure due to the progressive aging of the population, the extensive application of cardiac interventional techniques, the rising rates of obesity and diabetes mellitus, coexistence of heart failure and renal failure in the same patient are frequent. More than half of subjects with heart failure had renal impairment, and mortality worsened incrementally across the range of renal dysfunctions. In patients with heart failure, renal dysfunction can result from intrinsic renal disease, hemodynamic abnormalities, or their combination. Severe pump failure leads to low cardiac output and hypotension, and neurohormonal activation produces both fluid retention and vasoconstriction. However, the cardiorenal connection is more elaborate than the hemodynamic model alone; effects of the renin-angiotensin system, the balance between nitric oxide and reactive oxygen species, inflammation, anemia and the sympathetic nervous system should be taken into account. The management of cardiorenal patients requires a tailored therapy that prioritizes the preservation of the equilibrium of each individual patient. Intravascular volume, blood pressure, renal hemodynamic, anemia and intrinsic renal disease management are crucial for improving patients' survival. Complications should be foreseen and prevented, looking carefully at basic physical examination, weight and blood pressure monitoring, and blood, urine urea and electrolytes measurement.

Dialysis initiation and survival in patients with refractory congestive heart failure.

BACKGROUND: It has been reported that more than 30% of patients present with congestive heart failure at the initiation of renal replacement therapy (RRT). We followed up a cohort of patients with refractory congestive heart failure (RCHF) who started dialysis between 2005 and 2006 and conducted an observational cohort study in order to evaluate the clinical features at the time RRT was started, and the survival rate of patients with RCHF METHODS: Data were collected on 33 uremic subjects (24 male) with RCHF, referred by cardiologists, who started dialysis between 2005 and 2006 and were followed-up for 42 months. The following parameters were derived from clinical records: age, sex, history of ischemic heart disease (IHD), cerebrovascular disease (CVD), peripheral vascular disease (PVD), diabetes, smoking, hypertension, myeloma or malignancies, the cause for dialysis and procedure used to initiate treatment. RESULTS: RCHF was the cause of initial RRT in 15 patients in 2005 and in 18 the following year with an incidence of 27 out of 100 patients per year. Diabetes was diagnosed in 51% (n = 17) of cases. More than 80% of patients with RCHF had histories of hypertension and smoking. IHD, CVD and PVD were present in 66%, 30% and 54% of cases, respectively. Cancers were recorded in 36% of subjects. Fluid overload was the cause of urgent dialysis in 73% of cases; a central venous catheter (CVC) was placed in 75% of patients. Mean survival of patients with RCHF was 23 months. Eighteen patients died because of cardiovascular events after a mean follow-up of 365 +/- 387 days; they had higher prevalence of a smoking history (100% vs. 73%, p = 0.02) and CVD (44% vs. 13%, p = 0.05) than the survivors. CONCLUSIONS: In uremic patients starting dialysis, RCHF appears to be a frequent condition, comorbidity is high and they require urgent treatment by CVC because of fluid overload. Since RCHF is time- and resource-consuming, nephrologists need to ameliorate its management.

Management of secondary hyperparathyroidism in uremic patients: the role of the new vitamin D analogs.

Secondary hyperparathyroidism - a common comorbid condition in patients with chronic renal insufficiency - is considered a consequence of critical determinants such as hypocalcemia, phosphate retention and reduced levels of calcitriol production. In this complex mechanism, the skeletal apparatus and the nonskeletal targets such as vascular and heart valves are often involved, thus explaining the increased risk of cardiovascular morbidity and mortality of uremic patients. In this review we will focus on the major role played by Calcitriol deficiency as a trigger of secondary hyperparathyroidism and the crucial need for obiquitous vitamin D receptor activation in order to have an optimal PTH control and to obtain a modulation between inhibitors and inducers of soft tissue calcification. This review will also elucidate the possible role of paricalcitol - a new vitamin D analog - in conditioning morbidity and mortality of patients on renal replacement therapy (RRT).

Inappropriate left ventricular mass: Reliability and limitations of echocardiographic measurement for risk stratification and follow-up in single patients.

BACKGROUND: The appropriateness of left ventricular (LV) mass to cardiac workload may be calculated by the ratio of observed LV mass to the value predicted for an individual's sex, height, and stroke work at rest. OBJECTIVE: To investigate test-retest reproducibility of observed/predicted LV mass in a single patient. DESIGN AND METHODS: We measured intraclass correlation and interval of agreement between two M-mode tracings, recorded both at the same session and 3-10 days apart in 200 participants (45 +/- 13 years, body mass index 25 +/- 4 kg/m; 99 hypertensive and 101 normotensive; 50% of each group were women) in 16 centres in Italy. Tracings were read by two observers in each centre. RESULTS: The values of observed/predicted LV mass value ranged from 40.78 to 215.50%. On the same day, the within-observer 90% interval of agreement between tracings 1 and 2 was -23 to +20%. For day-to-day test-retest within-observer variability (average three cycles), the 90% interval of agreement of the observed/predicted LV mass was -30 to +32%. The 90% interval of agreement of test-retest between-observer variability was -25 to +25%. The categorical consistency of retest in the identification of subjects with appropriate LV mass, classified in the first study (i.e. > 73% and < 128%), was 90% (k = 0.87). CONCLUSION: Measurement of the appropriateness of LV mass in single patients allows acceptable risk stratification, with a coefficient of consistency similar to that reported for LV mass. The probability of a true change (90% chance) in observed/predicted LV mass over time is maximized for a single-reader difference greater than 22%, although lesser differences might also have clinical relevance.

The association between atrial septal aneurysm and mitral valve prolapse in patients with recent stroke and normal carotid arteries.

BACKGROUND: The association between mitral valve prolapse (MVP) and cryptogenic stroke is controversial. The Atrial Septal Aneurysm Multicenter Italian (ASA-MI) Study is a prospective multicenter study evaluating the prevalence of atrial septal aneurysm (ASA) in patients with a recent stroke and normal carotid arteries. The aim of the present research was to evaluate the frequency of ASA and its association with MVP in the stroke population and in the subgroup of young patients (< 55 years) included in the ASA-MI Study. METHODS: The study group included 245 of the 606 patients referred for transesophageal echocardiography (168 men and 77 women, mean age 65.7 +/- 21 years). All patients were selected on the basis of a recent episode of unexplained cerebral ischemia and were included in the study if they had normal carotid arteries. The control population included 245 patients (mean age 64.7 +/- 23 years) who underwent transesophageal echocardiographic evaluation during the same period for indications other than cerebral ischemia. The subgroup of young patients (< 55 years) included 90 patients (61 men and 29 women, mean age 49 +/- 5 years). RESULTS: The prevalence of MVP was 18% (95% confidence interval 8 to 21%) in the stroke population and 15% (95% confidence interval 7 to 20%) in the control population (chi 2 = 2.1, p = NS). The prevalence of MVP did not differ between young stroke patients (28.8%) and young controls (20%) (chi 2 = 0.835, p = 0.3). MVP was not significantly associated with stroke. We found an association between ASA and MVP: there was a higher incidence of MVP in stroke patients with an ASA than in patients without stroke or an ASA (40.9 vs 25%, p < 0.05). There was also a higher frequency of MVP associated with ASA in the group of young patients than in all patients of the ASA-MI Study (28.8 vs 18%, chi 2 = 20.313, p < 0.001). CONCLUSIONS: We found an association between ASA and MVP in patients with recent stroke and this association bore a higher risk of cerebral events than in patients without these abnormalities.

Pulmonary hypertension in dialysis patients: a cross-sectional italian study.

Introduction. Pulmonary hypertension (PHT) is an independent predictor of mortality. The aim of this study was to relate pulmonary arterial pressure (PAP) to the cardiovascular status of dialysis patients. Methods. 27 peritoneal dialysis (PD) and 29 haemodialysis (HD) patients (60 ± 13 years, 37 males, dialysis vintage was 40 ± 48 months) had PAP measured by echocardiography. Clinical and laboratory data of the patients were recorded. Results. PHT (PAP > 35 mmHg) was detected in 22 patients (39%; PAP 42 ± 6 mmHg) and was diagnosed in 18.5% of PD patients and 58.6% of HD patients (P = .0021). The group of subjects with PH had higher dialysis vintage (63 ± 60 versus 27 ± 32 months, P = .016), interdialytic weight gain (2.1 ± 1 versus 1.3 ± 0.9 Kg, P = .016), lower diastolic blood pressure (73 ± 12 versus 80 ± 8 mmHg, P = .01) and ejection fraction (54 ± 13 versus 60 ± 7%, P = .021) than the patients with normal PAP. PAP was correlated positively with diastolic left ventricular volume (r = 0.32, P = .013) and negatively with ejection fraction (r = -0.54, P < .0001). PHT was independently associated with dialysis vintage (OR 1.022, 95% CI 1.002-1.041, P = .029) and diastolic blood pressure (OR 0.861, 95% CI 0.766-0.967, P = .011). Conclusions. PHT is frequent in dialysis patients, it appears to be a late complication of HD treatment, mainly related to cardiac performance and cardiovascular disease history.

Association between atrial septal aneurysm and patent foramen ovale in young patients with recent stroke and normal carotid arteries.

BACKGROUND: Atrial septal aneurysm (ASA) has been considered a potential source of cardiogenic embolism for many years. The ASA Multicenter Italian (ASA-MI) Study evaluated the prevalence and characteristics of ASA in patients with stroke and normal carotid arteries compared with control patients without stroke. The purpose of the present study was to evaluate the frequency of ASA and the association with patent foramen ovale (PFO) in the subgroup of younger patients (aged less than 55 years) included in the ASA-MI Study. METHODS: The ASA-MI Study included 606 patients, enrolled between November 1990 and December 1996: 245 patients with a previous cerebral embolic attack and normal carotid study and a control group of 316 patients. They all underwent transthoracic and transesophageal echocardiography. The subgroup of younger patients aged less than 55 years included 90 patients (61 men and 29 women of mean age 49 +/- 5 years) (group AY). This group was evaluated and compared with an age- and sex-matched control population (61 men; of mean age 48 +/- 6 years) (group BY). RESULTS: The prevalence of ASA was 48.8% (95% confidence interval 40-61) in group AY and 22.2% in the group BY (95% confidence interval 18-33) (chi(2) = 5.968; p = 0.01). Morphological features were similar in the 2 groups of patients. ASA involved the entire septum in 52% of patients of group AY, and in 47.2% of group BY. The prevalence of PFO was 58.8% (95% confidence interval 43-62) in group AY and 28.8% in group BY (95% confidence interval 17-35) (chi(2) = 5.811; p = 0.01). A strong association was found between ASA and PFO. Of the 90 younger patients with stroke, 39 of 44 (88.6%) with ASA also had PFO, compared with 14 of 46 (30.4%) without ASA (chi(2) = 7.370; p = 0.007). CONCLUSION: We found that ASA and PFO were independent predictive factors for stroke in younger patients with stroke and normal carotid arteries and that the association between ASA and PFO bore an increased odds risk.