NT-proBNP, fluid volume overload and dialysis modality are independent predictors of mortality in ESRD patients.

BACKGROUND: N-terminal fragment of B-type natriuretic peptide (NT-proBNP) is a marker of both fluid volume overload and myocardial damage, and it has been useful as a predictor of mortality in patients with end-stage renal disease (ESRD). It has been suggested that continuous ambulatory peritoneal dialysis (CAPD), automated peritoneal dialysis (APD) and haemodialysis (HD) may have different effects on fluid volume and blood pressure control; however, whether the independent predictive value of NT-proBNP for mortality is preserved when analysed in conjunction with fluid overload and dialysis modality is not clear. METHODS: A prospective multicentre cohort of 753 prevalent adult patients on CAPD, APD and HD was followed up for 16 months. Plasmatic levels of NT-proBNP, extracellular fluid volume/total body water ratio (ECFv/TBW) and traditional clinical and biochemical markers for cardiovascular damage risk were measured, and their role as predictors of all-cause and cardiovascular mortality was analysed. RESULTS: NT-proBNP level, ECFv/TBW and other cardiovascular damage risk factors were not evenly distributed among the different dialysis modalities. NT-proBNP levels and ECFv/TBW were correlated with several inflammation, malnutrition and myocardial damage markers. Multivariate analysis showed that NT-proBNP levels and ECFv/TBW were predictors of both all-cause and cardiovascular mortality, independently of dialysis modality and the presence of other known clinical and biochemical risk factors. CONCLUSIONS: NT-proBNP is a reliable predictor of death risk independently of the effect of dialysis modality on fluid volume control, and the presence of other clinical and biochemical markers recognized as risk factors for all-cause and cardiovascular mortality. NT-pro-BNP is a good predictor of mortality independently of fluid volume overload and dialysis modality.

Cardiovascular and renal effects of bromocriptine in diabetic patients with stage 4 chronic kidney disease.

OBJECTIVE: The objective of this study was to investigate the effect of bromocriptine (BEC) on left ventricular mass index (LVMI) and residual renal function (RRF) in chronic kidney disease (CKD) patients with type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS: A 6-month double-blind randomized controlled trial was conducted in 28 patients with T2D and stage 4 CKD with increased LVMI. Fourteen patients received BEC (2.5 mg, initially 1 tablet with subsequent increase to three times a day) and 14 received a placebo (PBO; initially 1 tablet with subsequent increase to three times a day). Cardiovascular changes were assessed by monitoring 24 h ambulatory blood pressure, two-dimensional-guided M-mode echocardiography, and N-terminal brain natriuretic peptide (NT-proBNP) plasma levels. RRF was evaluated by creatinine clearance and cystatin-C plasma levels. RESULTS: Both BEC and PBO groups decreased blood pressure-but the effect was more pronounced in the BEC group. Average 24 h, diurnal and nocturnal blood pressures, and circadian profile showed improved values compared to the PBO group; LVMI decreased by 14% in BEC and increased by 8% in PBO group. NT-proBNP decreased in BEC (0.54 ± 0.15 to 0.32 ± 0.17 pg/mL) and increased in PBO (0.37 ± 0.15 to 0.64 ± 0.17 pg/mL). Creatinine clearance did not change in the BEC group and decreased in the PBO group. CONCLUSIONS: BEC resulted in a decrease on blood pressure and LVMI. BEC also prevented the progression of CKD while maintaining the creatinine clearance unchanged.

Bromocriptine induces regression of left ventricular hypertrophy in peritoneal dialysis patients.

Left ventricular hypertrophy (LVH) prevalence is very high in end stage renal disease (ESRD). It's a predictor of cardiac death in peritoneal dialysis patients. Noradrenalin, Angiotensin II and aldosterone are involved incardiac hypertrophy. Dopamine, acting at DA2 receptors inhibits norephinephrin release, antagonizes aldosterone and down-regulates AT1 receptor numbers, suggesting that DA2 agonists, like bromocriptine (BEC) could regress LVH. The objective of this study was to evaluate the changes in left ventricular mass in patients with ESRD in continuous ambulatory peritoneal dialysis (CAPD), by adding BEC to the treatment. An open clinical trial was conducted. Twenty patients were enrolled. Five formed the control group. Fifteen patients in the experimental group received BEC 2.5 mg three times daily over three months. M mode echocardiography and prolactin plasma levels were measured at the beginning and at the end of the study. The statistical analysis was performed using Student t test. The echocardiography reports showed a 24.4% decreased in left ventricular mass index (LVMI); the interventricular septum decreased 11.3%, the ejection fraction was not modified. The control group showed no difference. BEC-mediated decreases in left-ventricular mass in LVH patients on dialysis suggest that Dopaminergic agonists could be useful in caring for patients with ESRD and LVH.

Factores Hemorreológicos y viscosidad sérica en diabéticos. Primera diálisis peritoneal / Hemorrheologic factors and seric viscosity in diabetic patients during the first peritoneal dialysis

Objetivo: medir durante la primera diálisis peritoneal los factores hemorreológicos y viscosidad sérica de los pacientes con nefropatía diabética terminal.Material y métodos: se incluyeron 10 adultos diabéticos con nefropatía en etapa terminal, que requerían tratamiento dialítico peritoneal inmediato. En etapa basal, a mitad y final de diálisis se midieron biometría hemática, plaquetas, fibrinógeno, colesterol total, triglicéridos, creatinina, urea, sodio, potasio, cloro, albúmina, globulina y viscosidad sérica. Los valores fueron expresados en 8 ñ DE y se emplearon t de Student, ANOVA y coeficiente de relación y regresión lineal por mínimos cuadrados.Resultados: de acuerdo con las mediciones basal, a mitad y final de diálisis peritoneal, los factores que aumentaron fueron: viscosidad sérica [1.51 ñ 0.58, 2.04 ñ 0.7 y 2.44 ñ 0.56 (p < 0.01, r = 1, y = 0.45X)] y albúmina sérica [2.68 ñ 0.19, 2.77 ñ 0.22 y 3 ñ 0.22 gL (r = 0.6811, p < 0.05)]. El volumen total de agua ultrafiltrada fue de 5844 ñ 1093 mL y el peso corporal se redujo respectivamente a 59 ñ 8.7, 57.2 ñ 8.6 y 55.8 ñ 8.2 kg, en las mediciones. Conclusión: la viscosidad sérica antes de la diálisis peritoneal estuvo en el límite inferior y fue mayor al rango de referencia al final del procedimiento; la albúmina aumentó y la tensión arterial diastólica disminuyó significativamente. Los demás factores hemorreológicos no mostraron cambios significativos y hubo una débil relación con el incremento de la viscosidad sérica. La hemoconcentración provocada por la ultrafiltración de agua es la responsable de tales cambios.

Nuevos criterios de asignación a programas de diálisis peritoneal: impacto sobre la calidad de vida y la utilización de servicios / New criteria for assignation to programs of peritoneal dialyziz. Impact upon the quality of life and use of the services

El objetivo del estudio fue incrementar el uso del programa de diálisis peritoneal continua ambulatoria (DPCA), así como evaluar sus beneficios en los servicios hospitalarios y la calidad de vida del enfermo diabético con diálisis peritoneal. La intervención consistió en la definicion de nuevos criterios de asignación, la instalación de la "unidad de diálisis casera" en el domicilio del enfermo y la capacitación a un familiar para realizar la DPCA: La evaluación se llevó a cabo en 25 pacientes, que se encontraban bajo diálisis peritoneal intermitente (DPI). Se comparararon las condiciones clínicas y la calidad de vida del enfermo, así como la utilización de servicios entre los tres previos y los tres meses posteriores. Los resultados muestran que la estategia tuvo una efectividad del 96 por ciento para transferir a los efermos inicialmente en DPI al programa de DPCAS. La calidad de vida del paciente transferido a DPCA mejoró 52 por ciento con respecto a sus condiciones previas en DPI. Así mismo, mostró una importante reducción del 25 al 0.9 por ciento de la ocupación del Servicios de Medicina Interna por DPI en diabéticos; el total de días/cama en los tres meses previos a la intervención fue de 800 y en los tres posteriores fue únicamente de 33. Se considera que las propuestas operativas planteadas constituyen alternativas reales para la solución del problema en la atención de paciente diabético con insuficiencia renal crónica terminal dentro del Instituto Mexicano del Seguro Social