Relationship Between Cardiovascular Events and Serum Lipid and Plasma Fatty Acid Profile in Maintenance Hemodialysis Patients With Diabetic Mellitus.

BACKGROUND/AIM: Cardiovascular disease (CVD) is a frequent complication in hemodialysis (HD) patients, especially when the underlying disease is diabetes mellitus (DM). In this study, we investigated cardiovascular events and lipid and fatty acid profile in maintenance HD patients with diabetic kidney disease (DKD). PATIENTS AND METHODS: The subjects were 123 patients undergoing HD at Oyokyo Kidney Research Institute Hirosaki Hospital, who were considered to have DKD as the underlying cause of dialysis induction. Among these patients, the lipid and fatty acid profile were examined in two groups, CVD group (n=53) and non-CVD group (n=70), according to the presence or absence of a history of cardiovascular events (coronary artery disease, stroke, arteriosclerosis obliterans, valvular disease, and aortic disease). For serum lipid profile, the levels of total-cholesterol (T-C), triglycerides (TG), high density lipoprotein-cholesterol (HDL-C), and low density lipoprotein-cholesterol (LDL-C) were measured, and for fatty acid balance, 24 fractions of fatty acid composition in plasma total lipids were measured. These markers were compared between the CVD and non-CVD groups. RESULTS: The levels of T-C and TG were significantly lower in the CVD group compared with the non-CVD group (147.7±36.9 mg/dl vs. 159.2±35.6 mg/dl, p<0.05, 120.2±65.7 mg/dl vs. 143.8±124.4 mg/dl, p<0.05). In the plasma fatty acid composition, alpha-linolenic acid (ALA) and docosapentaenoic acid (DPA) were significantly lower in the CVD group compared with the non-CVD group (0.74±0.26 wt% vs. 0.84±0.31 wt%, p<0.05; 0.61±0.21 wt% vs. 0.70±0.30 wt%, p<0.05). CONCLUSION: Abnormal fatty acid balance, especially low levels of ALA and DPA, rather than serum lipids, are more likely the factors associated with cardiovascular events in maintenance HD patients with underlying DKD.

Delirium in hemodialysis predicts mortality: a single-center, long-term observational study.

OBJECTIVES: Delirium signifies underlying brain dysfunction; however, its clinical significance in hemodialysis remains unclear. In this study, we sought to determine whether the occurrence of delirium during hemodialysis was associated with higher mortality. PATIENTS AND METHODS: This was a retrospective, 10-year cohort study. This study was performed at the urology department located within a hospital in Oyokyo, Hirosaki. We analyzed 338 of 751 patients who underwent hemodialysis. Psychiatrists diagnosed patients with delirium according to the corresponding DSM-IV-TR criteria. Cox proportional hazard regression, which was adjusted for patient age at the time of hemodialysis initiation, sex, and the presence of diabetes mellitus, was performed. Hazard ratios (HRs) and their 95% CIs were also reported. RESULTS: In total, 286 patients without psychiatric diseases and 52 patients with delirium were evaluated. Eighty percent of patients with delirium died within 1 year of hemodialysis initiation, while only 22% of patients without delirium died within the same time period (P<0.01). Kaplan-Meier plots demonstrated the existence of associations between delirium and all-cause mortality (global log-rank P<0.001), cardiovascular disease-related mortality (global log-rank P<0.001), and infection-related mortality (global log-rank P<0.001). Moreover, Cox proportional hazard regression showed that delirium was associated with all-cause mortality (HR=1.96, 95% CI: 1.32-2.90), cardiovascular disease-related mortality (HR=2.65, 95% CI: 1.31-5.35), and infection-related mortality (HR=3.30, 95% CI: 1.34-8.10). CONCLUSION: Delirium is an independent predictor of death in patients undergoing hemodialysis.

Prevalence of major depressive disorder among hemodialysis patients compared with healthy people in Japan using the Structured Clinical Interview for DSM-IV.

BACKGROUND: We investigated the prevalence of depression in hemodialysis (HD) patients using the Center for Epidemiologic Studies for Depression (CES-D) scale and the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID) and compared the rates with those of community dwelling people in Japan. PATIENTS AND METHODS: A total of 99 patients undergoing HD were recruited. Blood sampling was performed no later than 2 weeks prior to assessment. As a reference group for SCID and CES-D evaluation, 404 age- and sex-matched healthy controls who had participated in the Iwaki Health Promotion Project were included in this study. The SCID and the CES-D scale were administered to all participants to diagnose their depression. Participants who met the criteria of a major depressive episode according to the SCID were classified as SCID depression and the participants whose CES-D score was 16 or higher were classified as CES-D depression. RESULTS: Ninety-nine HD patients completed the evaluation and data collection. There were no significant differences in age, sex, or CES-D scores between HD patients and controls. There were 12 cases of SCID depression in HD patients and four cases in controls. There was a significant difference between HD patients and controls in the prevalence of SCID depression. There were no significant differences between the two groups with regard to demographic or clinical data. There were 19 HD patients and 24 controls who showed CES-D depression. There was no significant difference between HD patients and controls in the prevalence of CES-D depression. There was a significant difference in potassium level between the two groups, but there were no significant differences in any of the other items. CONCLUSION: There were significantly more HD patients showing SCID depression than controls in the present study. In clinical settings, the SCID might be useful in surveying cases of depression detected by screening tools among HD patients.

Insomnia in patients on hemodialysis for a short versus long duration.

BACKGROUND: Many studies have investigated insomnia and the factors associated with this condition in hemodialysis (HD) patients, although the influence of HD duration has not been thoroughly investigated. In the present study, we investigated the factors, especially the duration of HD, associated with insomnia in HD patients. PATIENTS AND METHODS: A total of 138 patients undergoing HD were recruited, and the Japanese version of the Pittsburgh Sleep Quality Index (PSQI) was used to assess the quality of sleep. Subjects with a total PSQI score up to 4 and those with a score of at least 5 were identified as normal subjects and subjects with insomnia, respectively. Additionally, we assessed restless legs syndrome, depression using the Center for Epidemiologic Studies Depression Scale, and health-related quality of life (QOL) using the Short Form 8 Health Survey. We divided the subjects into two groups according to the median HD duration. RESULTS: The prevalence rate of insomnia was 54.3% among all the subjects. Twenty-one subjects (15.2%) had depression, 26 (18.8%) had restless legs syndrome, and 75 (54.3%) had insomnia. The median HD duration was 4 years. The scores of components 1 and 4 of the PSQI, subjective sleep quality and habitual sleep efficiency, did not show a significant difference between the normal and insomnia groups. The score of component 7, daytime dysfunction, showed a significant difference between the short and long HD duration groups. In multiple regression analysis, the score of the Short Form 8 Health Survey showed a significant association with the PSQI score in the long HD duration group, but no variable showed a significant association in the short HD duration group. CONCLUSION: Patients with a longer duration of HD indicated that insomnia has an influence on their daily activities, with a significant association between insomnia and QOL. Greater attention should be paid to poor QOL and troubles in daily activities caused by insomnia in patients with a longer HD duration.

Calcium ions are abnormally distributed in the skin of haemodialysis patients with uraemic pruritus.

BACKGROUND: Although a close relationship between uraemic pruritus and serum calcium levels has been demonstrated for some time, the degree of pruritus was not always correlated with calcium concentrations. In the present study, we assessed calcium ion distribution in the skin of chronic haemodialysis patients with and without pruritus. METHODS: We excluded patients with concomitant psoriasis or atopic dermatitis or with a previous history of allergy, those who had an arteriovenous fistula created prior to induction of haemodialysis, and patients with only mild pruritus. From the enrolled 22 haemodialysis patients, we obtained forearm skin samples during arteriovenous fistula surgery. These patients were divided into two groups based their grade of pruritus. The pruritus group included patients with moderate to severe grades of pruritus (n = 11, age 64 +/-13 years) and the non-pruritus group consisted of patients without pruritus (n = 11, age 59 +/-13 years). We compared the distribution of calcium ions in the epidermis between the two groups using the ion-capture method (oxalate-pyroantimonate-osmium technique). In addition, we examined and compared the groups for thicknesses of the basal, spinous and granular layers, as well as of the stratum corneum using an electron microscope. RESULTS: The pruritus group had significantly higher calcium ion deposition in the extracellular fluid and cytoplasm of basal cells, and in the extracellular fluid, nuclei and cytoplasm of spinous cells compared with the non-pruritus group. In contrast, calcium ion depositions were similar between the two groups in the dermis/basal layer interface, the nucleus of basal cells, the nucleus and cytoplasm of granular cells, exterior of granular cells, the granular cells/stratum corneum interface, and in the interior and exterior of corneocytes. Although the stratum corneum was significantly thicker in the pruritus group than in the non-pruritus group, there were no differences in basal cell, spinal cell or granular cell layer thicknesses. CONCLUSION: In chronic haemodialysis patients with pruritus, the calcium ion concentration in the deepest layer of the epidermis was increased, which indicated a disrupted calcium ion gradient in the skin. These findings point to a role for increased skin calcium ion concentrations in the development and/or maintenance of uraemic pruritus. However, more extensive studies in larger patient cohorts will be necessary to confirm this hypothesis.