Significant Association of Diabetes With Mortality of Chronic Hemodialysis Patients, Independent of the Presence of Obesity, Sarcopenia, and Sarcopenic Obesity.

OBJECTIVES: This retrospective cohort study investigated the association of diabetes with mortality in hemodialysis patients with regard to obesity, sarcopenia, and sarcopenic obesity, along with examining the prevalence of each group and diabetes. METHODS: Muscle strength, muscle mass, and fat mass were evaluated using a hand dynamometer and dual-energy X-ray absorptiometry, respectively, in 308 chronic hemodialysis patients (age 58.0 ± 11.9 years, hemodialysis duration 6.5 ± 6.0 years, males 60.1%, diabetes 32.8%). Sarcopenia was defined according to the new criteria established by the Asian Working Group on Sarcopenia 2019. Obesity was defined by percent body fat mass (males ≥25%, females ≥35%). RESULTS: The enrolled patients were divided into the normal (38.7%), obesity (18.8%), sarcopenia (26.9%), and sarcopenic obesity (15.6%) groups. The prevalence of diabetes was significantly skewed among the 4 groups (χ2 test, P = .0057), being higher in the sarcopenic obesity group (54.2%) compared to the others (25.9-33.7%). Multivariate regression analysis revealed that diabetes was significantly and independently associated with sarcopenic obesity (odds ratio 3.495, 95% confidence interval 1.683-7.255, P = .0008) after adjustments for several cofounders, but not significantly associated with sarcopenia. During the follow-up period of 76 ± 35 months, 100 patients died. Those in the sarcopenia and sarcopenic obesity groups had significantly higher rates of all-cause mortality compared to patients in the normal and obesity groups (P = .0004, log-rank test). Furthermore, multivariate Cox proportional hazards analysis revealed that presence of diabetes was significantly associated with higher all-cause mortality in all 308 patients, after adjustments for several factors, including the presence of each group in 4 models. CONCLUSION: Sarcopenic obesity is highly prevalent in chronic hemodialysis patients. Diabetes was found to be a significant and independent contributor to the presence of sarcopenic obesity. Diabetes was shown to be a significant predictor of all-cause mortality, independent of the present normal, obesity, sarcopenia, and sarcopenic obesity groups.

Impact of diabetes on sarcopenia and mortality in patients undergoing hemodialysis.

BACKGROUND: Sarcopenia has become a serious disorder in modern society. Chronic kidney disease requiring dialysis and diabetes are some of the disorders that accelerate the onset and progression of sarcopenia. We, therefore, investigated the prevalence of sarcopenia in patients undergoing hemodialysis (HD) and confirmed the impact of diabetes mellitus (DM) on this population. METHODS: This study included 308 patients whose muscle strength and mass had been evaluated using handgrip strength and dual-energy X-ray absorptiometry, respectively. Sarcopenia was defined according to the criteria established by the Asian Working Group on Sarcopenia. In addition, this cohort had been followed up for 9 years. RESULTS: The prevalence of sarcopenia was 40% (37% in males and 45% in females) with gender differences being insignificant (p = 0.237). The DM morbidity rate was significantly higher in those with sarcopenia than in those without sarcopenia (41% vs. 27%, p = 0.015). Multivariate regression analyses showed that the presence of DM was an independent contributor to sarcopenia in patients undergoing HD (odds ratio 3.11; 95% confidence interval 1.63-5.93; p <  0.001). During the follow-up of 76 ± 35 months, 100 patients died. Patients with sarcopenia demonstrated significantly higher rates of all-cause mortality than those without sarcopenia (p <  0.001 using the log-rank test). Multivariate Cox proportional hazards analyses revealed that the presence of DM was significantly associated with higher all-cause mortality (adjusted hazard ratio: 2.39; 95% confidence interval 1.51-3.81; p <  0.001). CONCLUSIONS: The prevalence of sarcopenia among this cohort of patients undergoing HD was determined to be 40%. Moreover, the presence of DM was an independent contributor to sarcopenia and an independent predictor of all-cause mortality in this population.

Inverse association of fat mass, but not lean mass, with glycated albumin in hemodialysis patients with or without diabetes mellitus.

Background: Glycated albumin (GA), which is independent of anemia and/or use of erythropoiesis-stimulating agents, might provide a more precise measure than glycated hemoglobin (HbA1c) in hemodialysis patients. The present study examines whether body composition is associated with GA besides glycemic control in hemodialysis patients. Methods: This study included 90 hemodialysis patients with diabetes mellitus (DM) and 86 hemodialysis patients without DM. We examined blood parameters after an overnight fast and body fat and lean mass using dual X-ray absorptiometry 21-24 h after completing the dialysis session. Results: The mean body mass index (BMI) was 22.0 kg/m2. BMI and truncal fat mass were significantly higher, and total fat mass tended to be higher in hemodialysis patients with DM than in those without DM. GA exhibited inverse correlations with BMI, total lean mass, total fat mass, and truncal fat mass in hemodialysis patients with and without DM; however, there was a lack of correlation with total lean mass in patients without DM. In multiple regression analysis including total fat mass and total lean mass simultaneously as independent variables, total fat mass (with DM: ß = -0.322, p = .006) (without DM: ß = -0.391, p < .001), but not total lean mass, in addition to log fasting plasma glucose, emerged as an independent factor associated with GA in hemodialysis patients with and without DM. When total fat mass was replaced with truncal fat mass (with DM: ß = -0.311, p = .007) (without DM: ß = -0.396, p < .001), the association remained significant and independent with GA in both patient groups. Conclusions: Higher total fat mass, particularly truncal fat mass, might be associated with lower GA levels, beside glycemic control, in hemodialysis patients with or without DM.

High Coronary Heart Disease Risk in Hemodialysis Patients with Central Sleep Apnea: A Pilot Study.

BACKGROUND: The high prevalence of sleep apnea is reported in hemodialysis patients despite the low prevalence of obesity. The present study compared the occurrence of central sleep apnea (CSA) in hemodialysis patients with that in non-hemodialysis patients, and its association with new-onset coronary heart disease (CHD) events. METHODS: Seventy-three hemodialysis and 444 non-hemodialysis patients were examined for CSA and obstructive sleep apnea (OSA) occurrence using polysomnography. Hemodialysis patients were monitored for the occurrence of new-onset CHD events. RESULTS: Hemodialysis patients had a significantly higher central apnea-hypopnea index (AHI; 0.7, range 0.2-3.1) than age-, sex- and obstructive AHI-matched non-hemodialysis patients (0.1, range 0-1.0; p < 0.001), in contrast with an insignificant difference for obstructive AHI. Furthermore, the prevalence of CSA was significantly higher in the hemodialysis (21.9%) than in the non-hemodialysis group (9.7%; p = 0.004). A significant and negative association existed between log (central AHI + 1) and Kt/V in hemodialysis patients. In the Kaplan-Meier analysis, hemodialysis patients with CSA had a significantly higher rate of new-onset CHD events than those without CSA. Cox proportional-hazards regression analysis identified CSA prevalence as an independent risk factor for the development of a new-onset CHD event, independent of OSA. CONCLUSIONS: The present study demonstrated that hemodialysis patients had a significantly higher CSA prevalence than non-hemodialysis patients despite similar obstructive AHI, and that hemodialysis patients with CSA had a significantly higher risk for new-onset CHD events than those without CSA independent of obstructive AHI, suggesting CSA as a potential CHD risk specifically in hemodialysis patients.

Association of Increased Serum Ferritin With Impaired Muscle Strength/Quality in Hemodialysis Patients.

OBJECTIVE: We reported previously that muscle quality and muscle strength provide clinically relevant predictors for better survival in hemodialysis patients. Iron overload might impair muscle function by its accumulation in muscle in such patients. METHODS: Serum ferritin, a marker for body iron store, was examined for its association with handgrip strength (HGS) and muscle quality which was defined as the ratio of HGS to arm lean mass measured with dual-energy X-ray absorptiometry. RESULTS: In 300 Japanese hemodialysis patients, age, hemodialysis duration, body mass index, and serum albumin were 58.0 ±12.0 (mean ± standard deviation) years, 4.2 (1.8-10.4) (median [25th-75th percentile]) years, 20.4 ± 2.8 kg/m(2), 4.0 ± 0.3 g/dL, respectively. Hemoglobin and hematocrit were 8.9 ± 1.2 g/dL, and 28.8 ± 3.9%, respectively, whereas transferrin saturation and serum ferritin were 29.8 ± 11.0% and 100 (54-172) ng/mL, respectively. Serum ferritin significantly correlated in a positive manner with the total dose of iron orally administered during the previous 6 months (r = 0.185, P = .0013). HGS and muscle quality were 23.1 ± 10.4 kg and 11.6 ± 3.8 kg/kg, respectively. In multivariate analysis to elucidate the factors associated with HGS and muscle quality in 300 hemodialysis patients, which included transferrin saturation and log serum ferritin, in addition to age, gender, hemodialysis duration, the presence/absence of diabetes, body mass index as independent variables, log serum ferritin emerged as a significant and independent factor which associated in a negative fashion with HGS (ß = -0.091, P = .0395) and tendency toward negative association with muscle quality (ß = -0.100, P = .0754). CONCLUSION: In summary, the present study demonstrated the significant association of serum ferritin with HGS and muscle quality in hemodialysis patients and thus suggested that we should be careful of iron overload to avoid its possible harmful effect on muscle in such patients.

Predialysis and Postdialysis pH and Bicarbonate and Risk of All-Cause and Cardiovascular Mortality in Long-term Hemodialysis Patients.

BACKGROUND: To date, very few studies have been carried out on the associations of pre- and postdialysis acid-base parameters with mortality in hemodialysis patients. STUDY DESIGN: An observational study including cross-sectional and 1-year analyses. SETTING & PARTICIPANTS: Data from the renal registry of the Japanese Society of Dialysis Therapy (2008-2009), including 15,132 dialysis patients 16 years or older. PREDICTOR: Predialysis pH<7.30, 7.30 to 7.34 (reference), 7.35 to 7.39, or ≥7.40 (1,550, 4,802, 6,023, and 2,757 patients, respectively); predialysis bicarbonate level < 18.0, 18.0 to 21.9 (reference), 22.0 to 25.9, or ≥26.0 mEq/L (2,724, 7,851, 4,023, and 534 patients, respectively); postdialysis pH<7.40, 7.40 to 7.44, 7.45 to 7.49 (reference), or ≥7.50 (2,114, 5,331, 4,975, and 2,712 patients, respectively); and postdialysis bicarbonate level < 24.0, 24.0 to 25.9, 26.0 to 27.9 (reference), or ≥28.0 mEq/L (5,087, 4,330, 3,451, and 2,264 patients, respectively). OUTCOMES: All-cause and cardiovascular (CV) mortality during the 1-year follow-up. MEASUREMENTS: HRs were estimated using unadjusted models and models adjusted for age, sex, dialysis vintage, history of CV disease, diabetes, weight gain ratio, body mass index, calcium-phosphorus product, serum albumin level, serum total cholesterol level, blood hemoglobin level, single-pool Kt/V, and normalized protein catabolic rate. RESULTS: Of 15,132 patients, during follow-up, 1,042 died of all causes, including 408 CV deaths. In the adjusted analysis for all-cause mortality, HRs compared to the reference group were significantly higher in patients with predialysis pH≥7.40 (HR, 1.36; 95% CI, 1.13-1.65) and postdialysis pH<7.40 (HR, 1.22; 95% CI, 1.00-1.49). Predialysis pH≥7.40 was also associated with higher risk of CV mortality (HR, 1.34; 95% CI, 1.01-1.79). No association of pre- or postdialysis bicarbonate level with all-cause and CV mortality was observed. LIMITATIONS: Single measurements of acid-base parameters, short duration of follow-up, small number of CV deaths. CONCLUSIONS: Predialysis pH≥7.40 was associated with significantly elevated risk of all-cause and CV mortality. However, pre- and postdialysis bicarbonate levels were not associated with all-cause and CV mortality. Predialysis pH may be the most appropriate reference for accurate correction of metabolic acidosis in dialysis patients.

Restoration of parathyroid function after change of phosphate binder from calcium carbonate to lanthanum carbonate in hemodialysis patients with suppressed serum parathyroid hormone.

Control of phosphate is the most critical in the treatment of chronic kidney disease with mineral and bone disorder (CKD-MBD). Because calcium-containing phosphate binder to CKD patients is known to induce adynamic bone disease with ectopic calcification by increasing calcium load, we examined the effect of lanthanum carbonate (LaC), a non-calcium containing phosphate binder, to restore bone turnover in 27 hemodialysis patients with suppressed parathyroid function (serum intact parathyroid hormone [iPTH] ≦ 150 pg/mL). At the initiation of LaC administration, the dose of calcium-containing phosphate binder calcium carbonate (CaC) was withdrawn or reduced based on serum phosphate. After initiation of LaC administration, serum calcium and phosphate decreased significantly by 4 weeks, whereas whole PTH and iPTH increased. A significant and positive correlation between decreases of serum calcium, but not phosphate, with increases of whole PTH and iPTH, suggested that the decline in serum calcium with reduction of calcium load by LaC might increase parathyroid function. Serum bone resorption markers, such as serum tartrate-resistant acid phosphatase 5b, and N-telopeptide of type I collagen increased significantly by 4 weeks after LaC administration, which was followed by increases of serum bone formation markers including serum bone alkaline phosphatase, intact procollagen N-propeptide, and osteocalcin. Therefore, it was suggested that LaC attenuated CaC-induced suppression of parathyroid function and bone turnover by decreasing calcium load. In conclusion, replacement of CaC with LaC, either partially or totally, could increase parathyroid function and resultant bone turnover in hemodialysis patients with serum iPTH ≦ 150 pg/mL.

Significant association between bone-specific alkaline phosphatase and vascular calcification of the hand arteries in male hemodialysis patients.

BACKGROUND/AIMS: Bone-specific alkaline phosphatase (BAP) hydrolyzes pyrophosphate, which inhibits vascular calcification. We examined association between serum BAP and vascular calcification of male hemodialysis patients. METHODS: Hand roentgenography of 167 male maintenance hemodialysis patients was conducted, and visible vascular calcification of the hand arteries was evaluated. Serum levels of 3 bone formation markers (BAP, osteocalcin, and N-terminal propeptide of type I collagen) and 2 bone resorption markers (C-terminal telopeptide of type I collagen, and cross-linked N-telopeptide of type I collagen) were measured, along with serum intact parathyroid hormone (PTH). RESULTS: Of 167 patients, visible vascular calcification was seen in 37 patients. Among the bone formation and resorption markers, serum BAP was significantly higher in patients with vascular calcification than in those without (p<0.05); although the other 5 serum bone markers were not significantly different between them. Multivariate logistic regression analyses revealed that log [BAP] was significantly associated with vascular calcification after adjustment for age, hemodialysis duration, presence of diabetes, log [intact PTH] and each of the other 5 bone markers (p<0.0001). CONCLUSIONS: Higher serum BAP, but not other bone markers, is significantly associated with the presence of vascular calcification in male hemodialysis patients.

Tumor necrosis factor-related apoptosis-inducing ligand as an independent predictor of mortality in hemodialysis patents.

BACKGROUND: Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) was originally isolated as an inducer of apoptosis in transformed cells. In addition to tumor surveillance, recent findings suggest that TRAIL and its receptor system have a protective role against infection and cardiovascular disease (CVD). Patients undergoing hemodialysis have a high mortality rate with a unique risk factor profile. Considering that the leading causes of death in these patients are infection and CVD, TRAIL represents an attractive candidate for predicting mortality in this population. We therefore investigated whether TRAIL predicted mortality in hemodialysis patients. METHODS: The study was a retrospective observational cohort design of 45-month duration in 149 male hemodialysis patients. The subjects were divided into two groups according to their baseline TRAIL level measured by ELISA (low or high TRAIL group). The main outcome was all-cause mortality. RESULTS: During the follow-up period, 33 patients died, mostly because of CVD (n=11) or infection (n=9). Crude survival analyses showed that a low TRAIL level was a powerful predictor of all-cause (p=0.011) and infectious mortality (p=0.048). The predictive power of TRAIL remained after adjustment for various confounding factors. CONCLUSIONS: The serum TRAIL level may be a novel biomarker for predicting prognosis in hemodialysis patients.

Greater potency of darbepoetin-α than erythropoietin in suppression of serum hepcidin-25 and utilization of iron for erythropoiesis in hemodialysis patients.

BACKGROUND: The potency of darbepoetin-α (DPO-α) to improve anemia in hemodialysis (HD) patients is greater than that of recombinant human erythropoietin (rHuEPO). DESIGN AND METHODS: To assess the potency of DPO-α to mobilize iron from body stores in comparison with rHuEPO in HD patients without apparent inflammation or infection, serum iron, transferrin saturation (TSAT), ferritin, and hepcidin-25 were measured serially. This study included (i) a long-term crossover study for 3 yr to compare the effects of the two erythropoiesis-stimulating agents (ESA) on serum iron, TSAT, and ferritin, and (ii) a short-term crossover study for 8 wk to examine their effects on serum hepcidin-25 in HD patients. RESULTS: The long-term crossover study demonstrated that the change of ESA from rHuEPO to DPO-α significantly decreased serum ferritin while serum iron and TSAT remained unchanged, while DPO-α as well as rHuEPO maintained hemoglobin level in the target range between 10.0 and 11.0 g/dL. Furthermore, in the short-term crossover study, area under the percent suppression of serum hepcidin-25 time curve for the first 7 d during the DPO-α treatment period was significantly greater than that during the rHuEPO period (348.0 ± 92.4 vs. 178.4 ± 131.5%.day P = 0.030). The greater suppression of hepcidin-25 by DPO-α may facilitate iron mobilization, resulting in diminution of body iron stores without any significant effect on serum iron utilizable for erythropoiesis. CONCLUSION: This study demonstrated that DPO-α has a greater advantage than rHuEPO in that it facilitates iron mobilization from body stores into bone marrow to induce effective erythropoiesis and thus could protect against possible harmful effects caused by excessive iron stores in the body.

Delamination of Acuseal arteriovenous graft: Two case reports.

Acuseal arteriovenous graft is an early cannulation graft having a tri-layered structure with an elastomeric middle layer. However, delamination of Acuseal grafts has been reported recently. This article describes two cases with different characteristics of Acuseal delamination. In case 1, the delamination occurred 1 month after a percutaneous transluminal angioplasty (PTA); therefore, the PTA was suspected to be a trigger. The delamination was located between the outer expanded polytetrafluoroethylene (ePTFE) layer and the elastomeric middle layer. On the other hand, in case 2, the delamination was located between the luminal ePTFE layer and the elastomeric middle layer. A surveillance ultrasound examination detected the delamination unexpectedly in the uneventful course; however, the delaminating location corresponded to the cannulation puncture site and the intraoperative findings suggested the involvement of mis-needling as a possible cause. Interestingly, for the purpose of continued use on hemodialysis, specific treatments were required against the delamination itself in both cases. As we identified Acuseal delamination in 5.6% (2/36) of cases, concerns arise that numerous cases of Acuseal delamination may have been overlooked in general. Understanding and recognizing this phenomenon are important for adequate use of Acuseal graft.

Relationship between fat mass and serum high-sensitivity C-reactive protein levels in prevalent hemodialysis patients.

BACKGROUND/AIMS: Little is known about the relationship between fat mass distribution and chronic inflammation in dialysis patients, in whom chronic inflammation is related to morbidity and mortality. METHODS: The fat and lean masses (truncal and nontruncal) of 452 hemodialysis patients (age: 64 ± 11 years; hemodialysis duration: 89 ± 77 months; 37% diabetics) were measured by dual X-ray absorptiometry and their association with high-sensitivity C-reactive protein (hsCRP) was examined. RESULTS: The fat mass of the high hsCRP group (n = 106) was significantly higher than that of the normal hsCRP group (n = 346; p < 0.05); there were no significant differences in lean mass between the two groups. Truncal fat mass of the former group was significantly greater than that of the latter (p < 0.05), but there was no significant difference in nontruncal fat mass between the two groups. In multiple regression analysis, truncal fat mass (ß = 0.227, p < 0.01) was significantly and independently associated with serum hsCRP levels after adjustment for age, gender and serum albumin (R(2) = 0.137, p < 0.01), whereas nontruncal fat mass was not. CONCLUSION: Fat mass, particularly truncal fat mass, but not lean body mass, was significantly associated with serum hsCRP levels. The results suggest that truncal fat mass exhibits a distinct effect on chronic inflammation in hemodialysis patients.

REM sleep latency as an independent risk for cardiovascular events in hemodialysis patients.

BACKGROUND: Clinical significance of objectively measured poor sleep quality (SQ) as a risk for cardiovascular disease (CVD) events is not well known in hemodialysis (HD) patients, independently of sleep-related breathing disorders (SRBDs) and sleep-related metabolic abnormality. METHODS: The present study investigated baseline levels of objective sleep architecture together with obstructive sleep apnea (OSA) and central sleep apnea (CSA) using polysomnography in 88 HD study participants (M/F, 56/32; age 68.4 ± 9.3). Then, HD study participants were monitored for the occurrence of new-onset CVD events with a median (range) follow-up period of 33 (1-64) months. RESULTS: Among various measures of SQ, log (REM sleep latency [REM-SL]) (interval between sleep-onset and the first REM period) alone correlated in negative manners with triglycerides and non-HDL-C in all study participants and with fasting plasma glucose and HbA1c in study participants with type-2 diabetes mellitus. In the Kaplan-Meier analysis, HD study participants with shorter REM-SL had a significantly higher rate of new-onset CVD events than those with longer REM-SL. Stepwise logistic regression analysis and multivariate Cox proportional hazard regression analysis identified shorter REM-SL as an independent risk factor for the development of a new-onset CVD events, independent of mean oxygen saturation, log (AHI+1), log (central AHI+1), diabetes mellitus, CVD history, systolic blood pressure, statins use, and non-HDL-C. CONCLUSIONS: The present study demonstrated that reduction of REM-SL is independently associated with a higher rate of new-onset of CVD events, independent of SRBDs (OSA and CSA) and diabetes mellitus, non-HDL-C in HD study participants, suggesting impaired SQ as a potential CVD risk factor, and thus a definite treatment target to protect against CVD specifically in HD study participants. REM-SL might be a new risk factor of CVD events in HD patients with SRBDs.

Cinacalcet may suppress kidney enlargement in hemodialysis patients with autosomal dominant polycystic kidney disease.

A massively enlarged kidney can impact quality of life of autosomal dominant polycystic kidney disease (ADPKD) patients. A recent in vitro study demonstrated that an allosteric modulator of the calcium sensing receptor decreases adenosine-3',5'-cyclic monophosphate, an important factor for kidney enlargement in ADPKD. Therefore, the present study was performed to determine whether cinacalcet, a calcium sensing receptor agonist, suppresses kidney enlargement in hemodialysis patients with ADPKD. Alteration of total kidney volume together with clinical parameters was retrospectively examined in 12 hemodialysis patients with ADPKD treated at a single institution in Japan. In the non-cinacalcet group with longer hemodialysis duration (n = 5), total kidney volume had an annual increase of 4.19 ± 1.71% during an overall period of 877 ± 494 days. In contrast, the annual rate of increase in total kidney volume in the cinacalcet group (n = 7) was significantly suppressed after cinacalcet treatment, from 3.26 ± 2.87% during a period of 734 ± 352 days before the start of cinacalcet to - 4.71 ± 6.42% during 918 ± 524 days after initiation of treatment (p = 0.047). The present findings showed that cinacalcet could be a novel therapeutic tool for suppression of kidney enlargement in hemodialysis patients with ADPKD.

Comparative Effects of Etelcalcetide and Maxacalcitol on Serum Calcification Propensity in Secondary Hyperparathyroidism: A Randomized Clinical Trial.

BACKGROUND AND OBJECTIVES: Vitamin D receptor activators and calcimimetics (calcium-sensing receptor agonists) are two major options for medical treatment of secondary hyperparathyroidism. A higher serum calcification propensity (a shorter T50 value) is a novel surrogate marker of calcification stress and mortality in patients with CKD. We tested a hypothesis that a calcimimetic agent etelcalcetide is more effective in increasing T50 value than a vitamin D receptor activator maxacalcitol. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A randomized, multicenter, open-label, blinded end point trial with active control was conducted in patients with secondary hyperparathyroidism undergoing hemodialysis in Japan. Patients were randomly assigned to receive intravenous etelcalcetide 5 mg thrice weekly (etelcalcetide group) or intravenous maxacalcitol 5 or 10 µg thrice weekly (maxacalcitol group). The primary, secondary, and tertiary outcomes were changes in T50 value, handgrip strength, and score of the Dementia Assessment Sheet for Community-Based Integrated Care System from baseline to 12 months, respectively. RESULTS: In total, 425 patients from 23 dialysis centers were screened for eligibility, 326 patients were randomized (etelcalcetide, n=167; control, n=159), and 321 were included in the intention-to-treat analysis (median age, 66 years; 113 women [35%]). The median (interquartile range) of T50 value was changed from 116 minutes (interquartile range, 90-151) to 131 minutes (interquartile range, 102-176) in the maxacalcitol group, whereas it was changed from 123 minutes (interquartile range, 98-174) to 166 minutes (interquartile range, 127-218) in the etelcalcetide group. The increase in T50 value was significantly greater in the etelcalcetide group (difference in change, 20 minutes; 95% confidence interval, 7 to 34 minutes; P=0.004). No significant between-group difference was found in the change in handgrip strength or in the Dementia Assessment Sheet for Community-Based Integrated Care System score. CONCLUSIONS: Etelcalcetide was more effective in increasing T50 value than maxacalcitol among patients on hemodialysis with secondary hyperparathyroidism. There was no difference in handgrip strength or cognition between the two drugs. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: VICTORY; UMIN000030636 and jRCTs051180156.

Effects of Long-Term Cinacalcet Administration on Parathyroid Gland in Hemodialysis Patients with Secondary Hyperparathyroidism.

BACKGROUND/AIM: Cinacalcet, an allosteric modulator of the calcium (Ca) sensing receptor, reduces the level of parathyroid hormone (PTH) in serum as well as parathyroid gland volume following administration in hemodialysis patients with secondary hyperparathyroidism, though long-term results are yet to be reported. METHODS: Serum parameters (n = 23), together with total parathyroid gland volume (n = 18), were determined in Japanese hemodialysis patients given cinacalcet treatment for 8 years. RESULTS: Following initiation of cinacalcet therapy, levels of serum Ca, phosphate, and intact PTH were significantly decreased. Furthermore, the baseline total volume of the parathyroid gland was 1,272 mm3 (496-2,836 mm3), which was then decreased after 6 months to 796 mm3 (377-1,146 mm3) and then to 332 mm3 (175-570 mm3) after 8 years. There was significant positive correlation between parathyroid gland volume at the start of cinacalcet treatment and reduction in volume during the 8 years cinacalcet treatment. The dose of phosphate binder was significantly decreased in a time-dependent manner after 8 years of cinacalcet treatment, likely because serum phosphate showed a progressive decrease with the treatment. CONCLUSION: In the present patients, long-term treatment with cinacalcet progressively decreased the total volume of parathyroid glands, as well as levels of intact PTH and phosphate in serum in a time-dependent manner. On the contrary, cinacalcet administration did not cause secondary failure or over-suppress the transition of parathyroid gland activity to hypoparathyroid status. These results suggest that cinacalcet treatment may postpone the need for parathyroidectomy and/or reduce its use even after long-term administration for up to 8 years.

Significant correlation of glycated albumin, but not glycated haemoglobin, with arterial stiffening in haemodialysis patients with type 2 diabetes.

OBJECTIVE: We recently reported that glycated albumin (GA) is a better indicator of glycaemic control compared with glycated haemoglobin (HbA1c) in haemodialysis (HD) patients with type 2 diabetes. As poor glycaemic control is considered an independent risk factor for atherosclerosis in diabetes, the relationship between GA, HbA1c and arterial stiffening was examined in HD patients with type 2 diabetes. PATIENTS AND METHODS: The present study comprised 134 HD patients with type 2 diabetes, and 158 patients without diabetes. Brachial-ankle pulse wave velocity (baPWV) was measured in all patients using a waveform analyser. RESULTS: The mean plasma glucose (PG), GA and HbA1c levels were 7.49 +/- 2.28 mmol/l, 20.8 +/- 5.57% and 5.62 +/- 1.26%, respectively, in HD patients with diabetes (n = 134), which were significantly greater than the respective values of 5.77 +/- 1.89 mmol/l, 15.6 +/- 2.34% and 4.98 +/- 0.80% in those without diabetes (n = 158) (P < 0.0001). BaPWV was 21.69 +/- 6.90 m/s in HD patients with diabetes, which was significantly greater than the value of 18.74 +/- 4.89 m/s in those without diabetes (P < 0.0001). When the analysis was performed in a combined population of those patients with and without diabetes, the mean PG (r = 0.155, P < 0.05) and GA (r = 0.117, P < 0.05), but not HbA1c (r = 0.092, P = 0.125), exhibited significant correlations with baPWV. Multivariate regression analysis, which included age, gender, mean blood pressure, and serum levels of albumin, creatinine and LDL cholesterol, to evaluate the independent association of each marker for glycaemic control with baPWV values in HD patients demonstrated that GA, but not HbA1c or PG, was an independent factor that was significantly associated in a positive manner with baPWV in HD patients. CONCLUSION: It was suggested that poor glycaemic control, as reflected by increased GA values, might be associated with increased arterial stiffening in HD patients.

Paradoxical positive association of serum adiponectin with all-cause mortality based on body composition in Japanese haemodialysis patients.

We have previously reported a paradoxical association of serum adiponectin with aortic calcification in haemodialysis patients. Because serum adiponectin is a nutritional marker, we examined the association between serum adiponectin and all-cause mortality based on body composition in haemodialysis patients. The trunk and total body fat were determined. The patients were divided into two groups based on serum adiponectin levels. In Kaplan-Meier analysis, the higher adiponectin group showed higher mortality than the lower adiponectin group. Serum adiponectin showed an inverse correlation with the percentage of truncal fat, suggesting serum adiponectin as an inverse marker for adiposity in haemodialysis patients. However, even after adjustment for other factors, multivariate Cox proportional hazards analysis identified higher serum adiponectin as an independent factor positively associated with higher mortality in haemodialysis patients. This association held true even when the total fat mass was replaced with the percentage of truncal fat, and when total fat mass and percentage of truncal fat were simultaneously included. Thus, we found a paradoxical association of higher serum adiponectin with higher all-cause mortality in Japanese haemodialysis patients, independent of adiposity.

The association of serum adiponectin with abdominal aortic calcification in Japanese male hemodialysis patients: a cross-sectional observational study.

The negative relation of serum adiponectin to atherosclerosis becomes a positive association in patients with chronic kidney disease (CKD). We conducted a small-scale cross-sectional observational study, in 101 Japanese male hemodialysis patients, to examine the relationship of serum adiponectin and leptin to abdominal aortic calcification (AAC). The presence of AAC was evaluated from simple X-ray radiographs of the left lateral abdomen. Serum adiponectin was significantly higher in AAC-positive patients [18.8 (13.0-28.1) µg/mL] than in AAC-negative patients [15.4 (8.9-22.8) µg/mL] (p = 0.03), whereas serum leptin did not differ significantly between the two groups. Multiple logistic regression analysis showed that log adiponectin, but not log leptin, was independently and significantly associated in a positive manner with AAC (odds ratio: 16.31, 95% confidence interval: 1.70-156.41, p = 0.02), after adjustment for age, body weight, percentage body fat, hemodialysis duration, prevalence of diabetes mellitus, and other risk factors. In conclusion, we found a positive and independent association of serum adiponectin with AAC in male hemodialysis patients, indicating that the reversed association between serum adiponectin and atherosclerosis in patients with CKD dose not result from increased serum adiponectin due to the impaired urinary secretion.