Quality of life as indicator of poor outcome in hemodialysis: relation with mortality in different age groups.

BACKGROUND: Physical, cognitive and psychosocial functioning are frequently impaired in dialysis patients and impairment in these domains relates to poor outcome. The aim of this analysis was to compare the prevalence of impairment as measured by the Kidney Disease Quality of Life- Short Form (KDQOL-SF) subscales between the different age categories and to assess whether the association of these subscales with mortality differs between younger and older dialysis patients. METHODS: This study included data from 714 prevalent hemodialysis patients, from 26 centres, who were enrolled in the CONvective TRAnsport STudy (CONTRAST NCT00205556, 09-12-2005). Baseline HRQOL domains were evaluated for patients <65 years, 65-74 years and over 75 years. Multivariable Cox proportional hazards analyses were performed to assess the relation between the separate domains and 2-year mortality. RESULTS: Emotional health was higher in patients over the age of 75 compared to younger patients (mean level 71, 73 and 77 for increasing age categories respectively, p = 0.02), whilst physical functioning was significantly lower in older patients (mean level 60, 48 and 40, p < 0.01). A low level of physical functioning (Hazard Ratio (HR) 1.72 [95%Confidence Interval (CI) 1.02-2.73]), emotional health (HR 1.85 [95% 1.30-2.63]), and social functioning (HR 1.59 [95% CI 1.12-2.26]), was individually associated with an increased 2-year mortality within the whole population. The absence of effect modification suggests no evidence for different relations within the older age groups. CONCLUSIONS: In dialysis patients, older age is associated with lower levels of physical functioning, whilst the level of emotional health is not associated with age. KDQOL-SF domains physical functioning, emotional health and social functioning are independently associated with mortality in prevalent younger and older hemodialysis patients.

[New study evaluating online haemodiafiltration for the reduction of cardiovascular morbidity and mortality in patients undergoing chronic haemodialysis]. / Nieuw onderzoek naar online-hemodiafiltratie voor de vermindering van cardiovasculaire morbiditeit en mortaliteit bij patiënten die chronisch worden behandeld met hemodialyse.

Removal of uraemic toxins can be increased by online haemodiafiltration. At present, it is unclear whether online haemodia-filtration ultimately improves clinical outcomes in chronic haemodialysis patients. The Dutch 'Convective transport study' (CONTRAST) is an ongoing trial comparing standard haemodialysis with online haemodiafiltration. This randomised controlled trial will provide substantial clinical evidence on the effects of haemodiafiltration on fatal and non-fatal cardiovascular events and all-cause mortality, compared with standard haemodialysis.

Relationships between undernutrition prevalence among children and adult women at national and subnational level.

OBJECTIVES: The objective of this study is to analyze the relationships between undernutrition prevalence rates among children and adults, both at the level of countries and at the level of smaller geographical subunits within countries (districts, provinces). Results are considered of relevance for evaluation and proper usage of anthropometric information in poverty and food security assessment. DESIGN: Anthropometric information on both children and adults, as reported in the Demographic and Health Surveys, has been the primary source of data. In addition, data published by WHO, FAO, and data from some country specific reports have been used. The final analysis is based on data from 289 subnational geographical units divided over 56 countries in Africa, Asia and Latin America. Ordinary least squares has been used for regression analysis and F-tests for testing differences of variances. RESULTS: At the level of countries, results reveal a strong positive relationship between undernutrition prevalence rates among children and adults. At the level of smaller geographical units, high levels of undernutrition in adult women are almost invariably associated with high levels of undernutrition in children. At the same time, however, low or intermediate levels of undernutrition among adult women are no guarantee that undernutrition levels among children are also low or moderate. CONCLUSION: At the level of countries, information on undernutrition prevalence in children can be considered a proximate of the overall nutritional and food security conditions in a country. At the level of smaller geographical units, relationships are less straightforward, and are hypothesized to depend, at least partially, on the relative importance of food and nonfood factors in the causation of undernutrition.

Reverse epidemiology: paradoxical observations in haemodialysis patients.

Traditional risk factors, such as high blood pressure (BP), obesity and hypercholesterolaemia, play an important role in the development of cardiovascular disease (CVD), not only in the general population but also in patients with chronic renal disease. In recent years, it has become less clear whether these conventional risk factors are responsible for the extremely high risk of CVD in chronic haemodialysis (CHD) patients. Recent studies have shown that low BP, body mass index (BMI) and serum cholesterol are often correlated with an unfavourable clinical outcome. Thus, whereas traditional risk factors of CVD are correlated with an unfavourable outcome in the general population and patients with chronic renal failure not yet on dialysis, in CHD patients these factors appear to be protective and associated with an improved survival. Therefore, these phenomena have been referred to as 'paradoxical or reverse epidemiology'. The aetiology of this inverse relationship is not clear. Interestingly, in CHD patients, both C-reactive protein, a marker of inflammation, and (pre)albumin, a marker of nutrition, are important independent predictors of mortality. It has been speculated that what is known as the malnutritioninflammation-atherosclerosis complex underlies, at least partly, the phenomenon of reverse epidemiology, since malnutrition causes a low BMI and hypocholesterolaemia. Hence, besides care for adequate nutrition, attempts should be made to reduce inflammation. In this respect, various haemodialysis-related factors, such as the purity of the dialysate and several characteristics of the dialyser, deserve attention.

Hepcidin in chronic kidney disease: not an anaemia management tool, but promising as a cardiovascular biomarker.

Hepcidin is a key regulator of iron homeostasis and plays a role in the pathogenesis of anaemia of chronic disease. Its levels are increased in patients with chronic kidney disease (CKD) due to diminished renal clearance and an inflammatory state. Increased hepcidin levels in CKD patients are supposed to be responsible for functional iron deficiency in these patients and contribute to renal anaemia and resistance to erythropoiesis-stimulating agents. Therefore, hepcidin was purported to be useful as a management tool guiding treatment of renal anaemia. Furthermore, since hepcidin is associated with iron accumulation in macrophages in the vessel wall inducing oxidative stress and atherosclerosis, it has been speculated that hepcidin might function as a biomarker of cardiovascular disease. In this descriptive review, the merits of hepcidin with respect to its role in the pathophysiology of renal anaemia in CKD patients, its presumptive role as a practical diagnostic tool guiding management of renal anaemia, and its possible usefulness as a prognostic biomarker will be discussed.

Simultaneous and consecutive administration of nutrients in parenteral nutrition.

In seven patients, six with Crohn's disease and one with pancreatitis, two methods of parenteral nutrition were compared: the partial consecutive administration of the components of a parenteral nutrition regimen versus the administration of all nutrients simultaneously. With respect to the consecutive regimen, the simultaneous infusion regimen gave an improvement in the nitrogen balance of 13% and a decrease in urinary lactic acid of about 50%. Urinary excretion of alpha-amino nitrogen, glucose, and fructose was very small in both cases but was slightly lower during the simultaneous infusion regimen. The improvement in the nitrogen balance attained with the simultaneous infusion regimen can be explained by the fact that infused nutrients, especially carbohydrates, cause fewer metabolic disturbances. The simultaneous infusion regimen has three other advantages. The patients rarely complain of headache and nausea, the infusion regimen is markedly simplified and the risk of contamination when nutrients are added to the infusion bottles in the ward is considerably diminished.

Beneficial effect of HLA-A and B matched pretransplant blood transfusions on primary cadaveric kidney graft survival.

The effects of HLA-A and B matched pretransplant blood transfusions on the survival of a primary cadaveric kidney graft were studied prospectively in a group of 15 patients who had never received a transfusion and had never been pregnant. Kidney graft survival at one year was 87%, whereas a group of 14 nontransfused patients who underwent transplantation in the same center (before this study was initiated) had a graft survival of only 7%. Twenty-six patients who received a transplant in the same center just before and after each protocol patient served as controls. There were no prior pregnancies in this group; all patients had received blood transfusions from random blood bank donors. Kidney graft survival at one year was 76% for this control group, which is not statistically different from that found for the protocol group. Graft survival for the 13 contralateral kidneys from the protocol group donors was only 50% at one year. These kidneys, however, were transplanted in various other centers. From our study, prolongation of kidney graft survival could be demonstrated for patients receiving pretransplant HLA-A-and-B-matched blood transfusions. Sera screening indicated that lymphocytotoxicity might be reduced by pretransplant HLA-A-and-B-matched blood transfusions. The presence of pretransplant antibodies with specificities for HLA-A and/or B could be significantly correlated with poor graft survival.

Prosthesis endocarditis: treatment of a case occurring five years after a Rastelli-Ross operation.

A severe staphylococcal septicemia originating from an unknown focus occurred in a 17-year-old patient who had undergone a Rastelli-Ross operation 5 years earlier. The clinical course was complicated by extensive bilateral pneumonia, diffuse intravascular coagulation, and glomerulonephritis. After 4 weeks of intensive conservative treatment, including a daily regimen of 16 Gm. of cloxacillin, the patient was operated upon for a rapidly progressive false aneurysm, which had resulted from dehiscence of the anastomosis between the prosthesis and ventricle. The excised prosthesis proved to be sterile. The postoperative course was uneventful. Cloxacillin treatment was continued for 6 months, initially parenterally and later orally. After discontinuation of therapy, no signs of infection have occurred. Right-sided intracardiac or intravascular prosthetic material may be particularly susceptible to infections originating from the body surface.

The determination of ammonium in Kjeldahl digests using the gas-sensing ammonia electrode. Comparison of the direct method with the known-addition method.

The efficacy of the ammonia electrode for analysis of the nitrogen content of a large series of Kjeldahl digests was investigated. By using this electrode, two methods for the measurement of ammonium concentrations were compared, the direct method and the known-addition method. When the direct method was used, a marked shift in the electrode potential occurred within a few hours, causing errors of 9-17% in the results. When the ammonium concentrations were calculated from the difference in electrode potential before and after addition of a known amount of an ammonium standard solution (known-addition method), it was possible to carry out reproducible measurements and the shift in the electrode potential did not influence the results. In two series of identical samples the coefficient of variation was respectively 1.45% and 0.80%.

Scoring of prudent dietary habits and its relation to 25-year survival.

To evaluate the effect on longevity of a diet that is concurrent with common dietary guidelines, a simple diet scoring system was developed and applied in a follow-up study of 2,820 middle-aged Dutch civil servants and their spouses. In the early 1950s those civil servants were seen for a health examination that included a dietary survey. Consumption frequency data of the quantitatively most important food items at that time were used for the diet scoring. Overall survival after 25 years was 46.8% among men and 68.6% among women. In men, a significant positive association between prudent diet score and 25-year, age-adjusted survival could be demonstrated. Of the 10 food items that constituted the diet score, a higher intake of brown bread, porridge and/or yogurt, vegetables, fish, and fruit was associated with a slightly better survival. In a separate analysis we had found a significant inverse relationship between coffee consumption and survival. A similar trend, which, however, was not significant, was observed for alcohol intake. In women, the results for the separate food items were inconsistent, and no effect of a prudent diet score on longevity was observed. The proposed diet scoring system provides a means for evaluating the effects of the individual's food choice behavior on subsequent health and longevity.

Large differences in nutritional status between fully weaned and partially breast fed children beyond the age of 12 months.

OBJECTIVE: To assess the effect of prolonged (partial) breastfeeding into the second and third year of life on the nutritional status of children. DESIGN, SETTING AND SUBJECTS: The analysis is based on data collected in the first two rounds of the nationally representative Ghana Living Standards Survey, held in 1987/88 (GLSS-I) and 1988/89 (GLSS-II), with both surveys covering approximately 3000 households. For the youngest child in each household the dataset provides information on mode of feeding and nutritional status, as well as on several household and individual level socio-economic characteristics. For both GLSS-rounds, the actual sample for analysis, which focuses on children 13-36 months, consisted of approximately 500 children. METHOD: Bivariate analysis was used to assess the relationship between prolonged (partial) breastfeeding and children's nutritional status. Multiple regression was used to estimate parameters, to determine levels of significance, and to control for confounding factors. RESULTS AND CONCLUSION: The data reveal a considerably lower nutritional status of children who continue to receive breastfeeding into their second and third year in comparison with fully weaned children of the same age. Differences in nutritional status between breastfed and nonbreastfed children cannot (only) be explained on the basis of differences in socio-economic conditions of households. It is hypothesized that, under conditions where infectious disease pressure is relatively low and where post-weaning child feeding practices are satisfactory, prolonged breastfeeding, either directly or indirectly, contributes to a lower nutritional status of children receiving prolonged breastfeeding in comparison with fully weaned children of the same age.

Body mass index as indicator of standard of living in developing countries.

OBJECTIVE: To assess the suitability of the body mass index (BMI) as an indicator of standard of living in developing countries. DESIGN, SETTING AND SUBJECTS: The analysis is based on data collected in the first two rounds of the Ghana Living Standards Survey, held in 1987/88 (GLSS-I) and 1988/89 (GLSS-II). The dataset provides information on a wide range of socio-economic variables, at the individual, the household and the community level, including the height and weight data of approximately 9000 adults in the 20-65 y age bracket. METHOD: Bivariate analysis was used to assess, at the individual level and at the level of population groups, the relationships between adult Body Mass Index and selected household characteristics such as income and expenditure, years of schooling of head of household, access to services, quality of housing, and nutritional status of children. Through multiple regression, indicative estimates have been derived of the effects of these variables on adult BMI. For comparison, the same relationships were investigated for weight and height. RESULTS AND CONCLUSION: At the individual level, BMI shows a significantly positive relation with the various socio-economic indicators of living standard, though the correlation coefficients indicate a poor fit. However, at the level of population groups, The relationship between BMI and other characteristics of socio-economic development is strong with a correlation coefficient of 0.86 between mean BMI and mean per capita expenditures of 12 population groups in Ghana, presumed to be at different levels of standard of living. The relationships between weight and the various socioeconomic characteristics were comparable to those for BMI, while height was poorly correlated with the selected household variables. Result suggest that in low-income countries, information on adult BMI (mean and distribution) can be used for assessing differences in standards of living between population groups or for monitoring changes over time.

Energy intake and the appearance of 5,8,11-eicosatrienoic acid in serum lipids during parenteral nutrition without fat.

During parenteral nutrition without fat, biochemical changes in fatty acid composition of serum lipids may occur, such as a decrease in the concentration of linoleic and arachidonic acid and an increase of 5,8,11-eicosatrienoic acid. In various reports on essential fatty acid deficiency in parenteral nutrition, the rates and degrees of these changes in fatty acid composition of serum lipids are different. We have tested the hypothesis that a relationship exists between the energy intake and the increase in 5,8,11-eicosatrienoic acid in parenteral nutrition without fat. The hypothesis is based on the assumption that mobilization of lipids from body fat, and thus of stored essential fatty acids, only takes place when energy intake is below requirements. Seventeen patients with gastrointestinal diseases were fed parenterally without fat during 1 to 5 weeks (mean 3.5 week). The energy supply to the patients varied from 88 to 222 kilo Joules per kilogram per day. In all patients, the fatty acid pattern of the serum phospholipid fraction was determined weekly. It appeared that those patients with the highest energy intake per kilogram body weight showed the lowest increase in 5,8,11-eicosatrienoic acid. In ten patients, energy was given as glucose and fructose, in seven patients as sorbitol. The type of carbohydrate investigated did not influence the changes in the fatty acid pattern. Results show further that the individual values of the concentrations of 5,8,11-eicosatrienoic acid and of arachidonic acid provide more information concerning the essential fatty acid status of a patient than the commonly used ratio of these two fatty acids.

Influence of erythropoietin treatment on urea kinetic parameters in hemodialysis patients.

Urea kinetic parameters were studied by means of dialysate collection in 8 stable hemodialysis patients before and after treatment with recombinant human erythropoietin (r-HuEPO), in order to investigate the impact of a rising hematocrit (Ht) on dialyzer performance and nutritional status. After 6 months, the average in vivo dialyzer urea clearance had fallen from 152 to 132 ml/min and consequently Kt/V values had become undesirably low in most of the patients in whom the relatively short dialysis regimens had been kept unchanged. There was also a significant decrease of protein intake. As a result of both changes there was only a moderate increase of predialysis mean blood urea concentration. These findings indicate that after correction of anemia by r-HuEPO dialyzer performance decreased. The concomitant decrease of protein intake seems to contrast to the improved general physical condition and appetite as indicated in the questionnaires. Although body weight remained the same, there might have been a tendency to avoid protein consumption with maintained total calory intake as a result of slight underdialysis. Therefore, in individual cases dialysis prescriptions may need reconsideration when Ht levels rise after r-HuEPO administration, especially in short dialysis regimens.

Bacterial and clinical sequelae of the Twin bag system in continuous ambulatory peritoneal dialysis. A single centre study.

Since the introduction of disconnect systems, a marked reduction in continuous ambulatory peritoneal dialysis (CAPD)-related peritonitis has been reported in the literature. At our centre too, a highly significant decline in the peritonitis rate was observed after the introduction of the Twin bag in 1990. In a multivariate analysis which we published recently, the Twin bag system, in conjunction with the more frequent use of the swan neck catheter, correlated significantly (p < 0.001) with an increase in the peritonitis-free interval. In the present study we retrospectively analyzed the bacteriological cultures of the peritonitis episodes, the antibiotic treatment prescribed, and the number of hospitalization days (HDs) before (non-Twin bag group; NTG) and after the introduction of the Twin bag system in our centre (Twin bag group; TG). In terms of absolute numbers, the decreased incidence of peritonitis in the TG was due by and large to a decline in all pathogenic micro-organisms, but mostly to a reduction of coagulase-negative staphylococci (CNS) compared with the NTG. The incidence of culture-negative episodes, however, showed no difference between the two groups. Proportionally, there was a significant increase in culture-negative peritonitis in the TG, whereas infections caused by CNS significantly decreased in comparison with the NTG (p < 0.01). The pattern of the antibiotics prescribed, i.e. mono- versus multi-drug regimens, did not differ between the two groups. Since, of all micro-organisms involved, CNS infections showed the largest decline in absolute numbers. Staphylococcus aureus increased relatively (43%) after the introduction of the Twin bag system.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term results of continuous ambulatory peritoneal dialysis: the first hundred patients. A single centre study.

In the present survey our experience on the first 100 patients on CAPD, treated from the start in 1982 till September 1991, is described. Sixteen were diabetics. Both the absolute numbers and the proportion of the total dialysis population have increased almost every year. Mean age did not change over the years due to an equilibrium between younger patients who received a transplant and elderly who stopped CAPD for other reasons. Patient survival at 3 years was 68%. Seventy patients stopped CAPD, of whom 25 died and 16 switched to haemodialysis. Twenty-four patients received a transplant, patient and transplant survival at 3 years being 89% and 77% respectively. Fifteen patients have had a follow-up period of 3 years or more, the longest being 123 months currently. Seventy-three CAPD-related complications occurred, the majority catheter-related. After the introduction of a 'break-in' period a significant reduction in leakage alongside the catheter was observed. In recent years there was a dramatic decrease in the incidence of CAPD-related peritonitis, from once every 8 to once every 30 months, which could be attributed mainly to the introduction of a new disconnect system in our centre, the so-called 'Twinbag'.

CAPD patients exhibit a nocturnal fall in blood pressure: a single-centre study.

BACKGROUND: In 29 CAPD (continuous ambulatory peritoneal dialysis) patients the height and diurnal variation of the blood pressure (BP) and heart-rate (HR) were analyzed by means of 24-hour ambulatory blood pressure monitoring (ABPM). METHODS: Normal diurnal variation was defined as a fall of 10% or more during nighttime (NT) compared with daytime (DT) BP or HR (DT = 10.00 a.m.-9.00 p.m., NT = midnight-06.00 a.m.). To evaluate high BP in the course of time we used the concept of "whole-day BP load", defined as the percentage of BP readings above 140/90 mmHg during a 24-h period. A "hypertensive BP load" was defined as a systolic BP (SBP) load of more than 50% and/or a diastolic BP (DBP) load in excess of 40%. In addition to analysis of the circadian rhythm of BP and HR and the prevalence of a hypertensive BP load in CAPD patients, the influence of various factors such as gender, creatinine clearance, recombinant human erythropoietin, antihypertensive medication, haematocrit, whole-day BP load, and the nightly dialysis glucose concentration on the diurnal variation of BP and HR were studied. RESULTS: Based on the 95% confidence intervals for the proportional nocturnal decrease, normal diurnal variation of BP and HR was present in most CAPD patients. No correlation could be demonstrated between a blunted circadian rhythm and the variables mentioned above. However, when other time-period definitions (DT = 6.00 a.m.-11.00 p.m., NT = 11.00-6.00 and DT = 8.00 a.m.-8.00 p.m., NT = 8.00 p.m.-8.00 a.m.) were applied to the data, considerably fewer patients displayed normal diurnal variation. Whereas all patients showed normal home BP readings, ABPM of 21 out of 29 patients displayed a hypertensive BP load. CONCLUSION: The majority of our CAPD patients exhibited normal diurnal variation of SBP and DBP depending, however, on the definitions of DT and NT used. The absence of a normal circadian rhythm could not be explained by any of the variables analyzed. Surprisingly, uncontrolled hypertension, as defined by a hypertensive BP load, was found in 72% of the patients.

Biocompatibility and performance of a modified cellulosic and a synthetic high flux dialyzer. A randomized crossover comparison between cellulose triacetate and polysulphon.

The biocompatibility and performance of two high flux membranes (modified cellulosic: cellulose-triacetate (CTA), and a synthetic material: polysulphon [PS]) were assessed in 31 stable patients on hemodialysis (HD) in a randomized crossover study. Parameters evaluated included leukocytes, complement activation products C3a and C5a, cytokines, lymphocyte subpopulations, urea, creatinine, phosphate, and beta 2 microglobulin. Considering biocompatibility, the drop in the number of leukocytes was more pronounced during CTA HD compared with PS (p = 0.045), although both were low in comparison with cuprammonium dialysis in the same patients, as observed during a separate study. Both membranes induced a low and transient state of complement activation. Interleukin 1 beta and interleukin 6 could not be detected at all, whereas tumor necrosis factor alpha levels were marginally elevated before and after HD with both membranes. During the first 30 min of HD with either membrane, the numbers of CD8+ cells decreased significantly, resulting in an increase in the CD4/CD8 ratios; in addition, the number of NK cells decreased. Performance, as measured by extraction ratios for small molecular weight solutes and Kt/V urea, was significantly better during CTA dialysis (p < 0.001), but almost similar after correction for membrane surface area. On the basis of these data, it seems justified to conclude that, whereas biocompatibility of the PS dialyzer appeared slightly superior to CTA, performance of both dialyzers was comparable.

[Proatherogenic changes induced by hemodialysis; probably a result of bio-incompatibility]. / Proatherogene veranderingen door hemodialyse; mogelijk een gevolg van bio-incompatibiliteit.

Chronic haemodialysis patients have a disproportionately high risk for developing cardiovascular disease, which can only in part be explained by known risk factors such as dyslipidaemia, hypertension, hyperhomocysteinemia, diabetes mellitus and chronic volume expansion. A possible cause is that the haemodialysis treatment itself contributes to the accelerated atherosclerosis, observed in these patients. Nowadays, atherosclerosis is considered an inflammatory process, mediated by a dysfunction of the vascular endothelium. As a result, blood cells adhere to the vascular surface and release a variety of vasoactive mediators, cytokines, growth factors and free radicals. Due to the contact between blood and dialyzer, humoral systems and cellular elements are stimulated, and this may be viewed as an inflammatory reaction. As a consequence of this, the vascular surface of haemodialysis patients is repeatedly exposed to the influences of cytokines, coagulation products, vasoactive mediators, stimulated leukocytes and thrombocytes, and oxidative stress. It is therefore conceivable that the haemodialysis treatment itself enhances the greatly increased cardiovascular risk in chronic haemodialysis patients.