FRAX prognostic and intervention thresholds in the management of major bone fractures in hemodialysis patients: A two-year prospective multicenter cohort study.

PURPOSE: The usefulness of FRAX in predicting major bone fractures in patients with end-stage kidney disease on maintenance hemodialysis treatment has been confirmed in previous studies. For meaningful clinical use, the prognostic and intervention FRAX thresholds need to be established. METHODS: The primary aim of our study was to calculate the optimal cut-off point of FRAX for the best prediction of an increased bone fracture risk in dialysis patients and additionally, to propose its intervention threshold, indicating the need for antifracture pharmacological treatment. The study included 718 hemodialysis patients, who were followed up for two years. Thirty low-energy major bone fractures were diagnosed during the study period. We used the Polish version of FRAX (without the DXA examination) and some particular variables of the FRAX calculator. The optimal cut-off point for prediction of an increased major bone fracture risk was based on the analysis of the sensitivity and specificity curves of FRAX. RESULTS: The analysis revealed FRAX >5% (sensitivity of 70.0%, specificity of 69.8%) as the prognostic threshold for major bone fractures. Its sensitivity for bone fracture prediction was significantly higher, but specificity lower than those of FRAX ≥10%, used in general Polish population. The reason for this can be an underestimation of bone fracture risk with FRAX in dialysis patients. CONCLUSIONS: We conclude that the FRAX prognostic threshold for identification of an increased risk of major bone fractures in hemodialysis patients is >5%. We propose to use this specific value of FRAX as an intervention threshold for pharmacological antifracture treatment in hemodialysis patients.

Value of multilocus genetic risk score for atrial fibrillation in end-stage kidney disease patients in a Polish population.

Genetic factors play a key role in the pathogenesis of atrial fibrillation (AF). We would like to establish an association between previously described single-nucleotide polymorphisms (SNPs) and AF in haemodialysed patients with end-stage kidney disease (ESKD-HD) as well as to assess the cumulative effect of all genotyped SNPs on AF risk. Sixteen SNPs were genotyped in 113 patients with AF-ESKD-HD and in 157 controls: without AF (NAF) and with ESKD-HD. The distribution of the risk alleles was compared in both groups and between different sub-phenotypes. The multilocus genetic risk score (GRS) was calculated to estimate the cumulative risk conferred by all SNPs. Several loci showed a trend toward an association with permanent AF (perm-AF): CAV1, Cx40 and PITX2. However, GRS was significantly higher in the AF and perm-AF groups, as compared to NAF. Three of the tested variables were independently associated with AF: male sex, history of myocardial infarction (MI) and GRS. The GRS, which combined 13 previously described SNPs, showed a significant and independent association with AF in a Polish population of patients with ESKD-HD and concomitant AF. Further studies on larger groups of patients are needed to confirm the associations.

Renal amyloidosis in Whipple disease: a case report.

INTRODUCTION: Whipple disease is a rare systemic infection caused by Tropheryma whippelii that usually manifests with joint pain, weight loss, diarrhoea and abdominal pain. However, in some cases the infection may involve other organs and tissues. CASE PRESENTATION: We report on a 44-year-old man with Whipple disease which led to renal amyloidosis and end-stage renal failure. In this case, the patient was diagnosed with Whipple disease and commenced on a 12-month trimetoprime-sulfametoxasole therapy with good result. Six months after cessation of therapy the patient was readmitted to hospital due to signs of renal failure. An urgent kidney biopsy was performed which revealed secondary amyloidosis. Despite intensive immunosuppressive treatment, renal parameters gradually deteriorated and haemodialysis was started eventually. Three months later the patient's general condition dramatically worsened with bloody diarrhoea, bilious vomiting and progressive malnutrition. The repeated endoscopic examination confirmed severe recurrence of Whipple disease. Ceftriaxone and total parenteral nutrition was started what greatly improved patient's state. CONCLUSIONS: To our knowledge based on systematic review, this is the first case report on Whipple disease complicated by secondary amyloidosis and kidney failure maintained on permanent renal replacement therapy. It is strongly suspected that the use of immunosuppressive treatment in such cases may exacerbate the course of Whipple disease and cause life-threatening complications.

Cardiovascular complications in patients with diabetic nephropathy receiving pharmacological versus renal replacement therapy.

INTRODUCTION: Diabetic nephropathy is a significant complication of diabetes mellitus and one of the major causes of renal replacement therapy. Cardiovascular complications are predominant causes of death in these patients. OBJECTIVES: To evaluate the influence of hemodialysis on cardiovascular risk factors and on their frequency in diabetic nephropathy patients. PATIENTS AND METHODS: 4 groups of renal failure patients were studied. Group 1 consisted of 71 hemodialyzed patients with non-diabetic nephropathy. Group 2 consisted of 29 hemodialyzed patients with diabetic nephropathy. Group 3 consisted of 50 patients with renal failure in the predialysis period (glomerular filtration rate < 60 ml/min). Group 4 consisted of 50 non-dialyzed patients with diabetic nephropathy in the pre-dialysis period. Complete blood count, blood gas, blood urea nitrogen, creatinine, glucose, lipidogram, electrolytes, parathormone, iron and dialysis adequacy (Kt/V) were assessed. Arterial blood pressure, resting ECG, echocardiography, body mass index, ankle-arm index, the prevalence of ischemic heart disease, myocardial infarction and chronic heart failure (NYHA classification) were also evaluated. RESULTS. In hemodialyzed patients with diabetic nephropathy lower complete blood count, less severe calcium-phosphate disorders, higher triglycerides and lower high-density lipoproteins cholesterol, with more frequent obesity, ischemic heart disease and peripheral arterial obstructive disease were found. Myocardial hypertrophy, cardiac arrhythmias, contractility disturbances, myocardial infarction and chronic heart failure were more common in the hemodialyzed patients, regardless of the cause of the renal disease. CONCLUSIONS: The risk factor for cardiovascular complications is greater in patients with diabetic nephropathy. Hemodialysis increases the frequency of cardiovascular complications in these patients and adversely affects the outcomes.

[Metoclopramide test in the patients with hyperprolactinemia due to end-stage renal failure]. / Test z metoklopramidem u chorych z hiperprolaktynemia w przebiegu schylkowej niewydolnosci nerek.

UNLABELLED: Evaluation of metoclopramide (MTC) test values in end-stage renal disease patients undergoing hemodialysis with different level of hyperprolactinemia was aim of the study. Clinical value of application of the MTC test and influence of different laboratory and clinical factors including erytropoietin treatment were examined. Sixty-eight hemodialysed patients (31 male and 37 female) aged 20-74 yr. (medium 48 +/- 13 yr.) underwent the MTC test, the control group consisted of 8 healthy volunteers (4 male and 4 female). 10mg of MTC was given i.v. and serum level of PRL was determined in 0, 30 and 60 min. after injection. Significant suppression of PRL stimulation in the patients was shown as compared with the controls after 30 min and delayed decrease of the curve values was found. An increase in the PRL level after 60 min in investigated group was lower than in control. Lower relative enhance of PRL level in 30 min was found and slower decrease after 60 min. Despite the slower decrease PRL level was lower in the patients than in the controls after 60 min. The highest relative increase in PRL level after 30 min was observed in the patients with lowest initial level of PRL (r=-0.471; p<0.001). Erytropoietin administration improved the response in the test (p=0.005) without relationship to the duration of erytropoietin treatment. There was influence of hemoglobin level on the results of the test. CONCLUSIONS: Results of the MTC test in end-stage renal disease patients is inadequate and the PRL response is diminished. Diagnostic value of the test in end-stage renal disease patients is low. Erytropoietin administration improves although not to the normal values the results of the MTC test.

Endometrial morphology and pituitary-gonadal axis dysfunction in women of reproductive age undergoing chronic haemodialysis--a multicentre study.

BACKGROUND: Although disorders of the reproductive system are very common in women undergoing chronic haemodialysis, this issue remains a neglected area. The aim of the study was to evaluate the endometrial morphology and its relationship with pituitary-gonadal axis dysfunction in uraemic women of reproductive age undergoing haemodialysis. METHODS: The baseline survey with determination of the sex hormones concentrations was performed in 75 haemodialysed women aged 18-45 years. The control group consisted of 33 healthy premenopausal women, aged 18-45 years, with normal menstruation. Then, 40 haemodialysis women, who met the inclusion criteria and gave their informed consent, underwent endometrium suction biopsy. RESULTS: The pathological endometrial morphology was observed in 80% of biopsied subjects. Atrophia or subatrophia was recognized in almost half of the cases, and proliferative changes in one-third of them. Full atrophia with no mitotic figures was found in all but one non-menstruating woman. In one case, adenocarcinoma in situ was diagnosed and successfully treated. The analysis of the relationship between hormonal status and endometrial morphology revealed the substantial influence of oestradiol on endometrium as a target organ. In women with atrophic changes, oestradiol concentrations were significantly decreased, whereas in the remaining subjects, the increase of serum oestradiol seemed to be accompanied by a shift in endometrium morphology from secretional pattern, through proliferative changes to glandular hyperplasia. Mean serum 17-beta oestradiol was decreased in women with amenorrhoea, and increased in those with eumenorrhoea (P<0.001). Except women with regular menses, mean serum progesterone concentrations were in the lower normal range. Seventy-five percent of the studied population had menstrual disorders, and amenorrhoea constituted almost a half of them. CONCLUSIONS: Pathological endometrium morphology is very common in uraemic women of reproductive age undergoing haemodialysis, with proliferative changes in one-third and atrophia in almost a quarter of them. The results of the study suggest a preserved normal reactivity of endometrium on circulating oestrogens.

[Management of hyperthyroidism with radioactive iodine in end-stage renal disease patients undergoing dialysis]. / Jod radioaktywny (I131) w leczeniu nadczynnosci tarczycy u chorych przewlekle dializowanych z powodu schylkowej niewydolnosci nerek.

Although, the abnormal thyroid hormone production and metabolism are relatively common, hyperthyroidism is a very unusual condition. The diagnosis may be difficult because of similar signs and symptoms as in uremia. To our knowledge till now only 18 well documented cases have been reported, 8 of them successfully treated with radioactive iodine. We report here the results of radioiodine treatment, performed in 6 patients, 5 with toxic multinodular goiter and one with Graves' disease. Three patients were initially treated with antithyroid drugs, but they were discontinued 20 days before radioiodine treatment. A progressive fall of the thyroid function tests was observed. Of 6 treated patients 3 became euthyroid and 3 developed hypothyroidism.

[Menstrual disturbances and alternations in hypophyseal gonadal axis in end-stage premenopausal women undergoing hemodialysis: a multi-center study]. / Zaburzenia miesiaczkowania i osi przysadkowo-gonadalnej u kobiet w wieku rozrodczym hemodializowanych z powodu schylkowej niewydolnosci nerek--badanie wieloosrodkowe.

The results of the studies of hypophyseal-gonadal axis in dialysis women are not uniform. Mostly the increased serum concentrations of prolactine and pituitary gonadotropins are observed; the data about ovarian secretion are much more scanty and contradictory. The aim of this crossectional study was to assess changes in sexual hormones secretion and their associations with menstrual disturbations in premenopausal women with end-stage renal failure undergoing hemodialysis. Sixty three women from six mazovian dialysis units, aged 18-45 years (mean 35 +/- 7 years) were enrolled into the study. They were divided into four groups according to their menstrual pattern: I--eumenorrhoea (n = 17), II--polymenorrhoea (n = 9), III--oligomenorrhoea (n = 16) i IV--amenorrhoea n = 21). There were no differences between both groups in respect to age, age of menarche, time on hemodialysis, and body mass index. In all subjects gynecological examination was performed and serum prolactin, FSH, LH, estradiol, progesterone and testosterone concentrations were assayed. In 49% women high serum prolactin concentrations were noted (the highest in group IV--1699 +/- 1022 vs 441 +/- 205 microIU/ml in group I; p < 0.05). Mean serum FSH and LH were increased in group IV only (33 +/- 59 and 22 +/- 31 mIU/ml); no significant differences among groups examined were seen. Serum estradiol was increased in groups I-III (95 +/- 46, 72 +/- 33, and 83 +/- 55 pg/ml, respectively) and decreased in group IV (27 +/- 22 pg/ml; p < 0.001 in respect to remaining groups). Mean serum progesterone and testosterone concentrations were normal in all four groups, but serum progesterone was significantly lower in groups II-IV than in group I (p < 0.05). No differences in hormonal status between patients receiving and not receiving rHuEpo were observed. Menstrual disturbances are common (73%) in premenopausal women with end-stage renal failure, with amenorrhea constituting a half of them. Hyperprolactinemia is the most frequently seen alteration in their hormonal profile with the highest concentrations in those with secondary amenorrhea. Increased serum gonadotropins and reduced serum estradiol concentrations are mostly seen in amenorrheic women, whereas in menstruating women serum estradiol is often slightly increased.