Type 2 idiopathic macular telangiectasia.

PURPOSE: To describe the natural course of Type 2 idiopathic macular telangiectasia in terms of visual outcomes, causes of visual loss, and incidence of subretinal neovascular membranes (SRNV). METHODS: This retrospective observational case series consisted of chart review of 104 outpatients (203 eyes; 66 women, 38 men) who were diagnosed to have Type 2 idiopathic macular telangiectasia by clinical examination and fluorescein angiography between January 2000 and December 2008. Visual and anatomic outcomes were analyzed during a minimum follow-up of 1 year. RESULTS: The mean age of the patients was 57 years (range, 40-74 years). Nineteen eyes (18 patients) presented with SRNV; the number increased to 29 eyes (14%; 23 patients) by the final visit (mean follow-up, 31 months). Diabetes was common (59%) though retinopathy was initially absent or mild to moderate in 99% patients. Mean logarithm of the minimum angle of resolution best-corrected visual acuity declined from 0.35 to 0.43 by the last visit (P < 0.0001) overall; final mean logarithm of the minimum angle of resolution best-corrected visual acuity was 0.61 (20/80) in the eyes with SRNV and 0.40 (20/50) in eyes without SRNV. The latter group started with better best-corrected visual acuity than SRNV group and remained better at 1-year, 2-year, and final follow-ups (P ≤ 0.0002). Overall, 30 eyes (15%; 24 patients) lost ≥ 2 Snellen lines, the main causes being SRNV and intraretinal pigment migration. Of 128 eyes (including SRNV) with best-corrected visual acuity ≥ 20/40 at baseline, 98 (77%) retained stable visual status; 74 (71%) patients retained best-corrected visual acuity of 20/40 or better at least in 1 eye. CONCLUSION: Over a follow-up of approximately 3 years, most eyes with Type 2 idiopathic macular telangiectasia starting with good vision were found to retain status quo; sight-threatening complications developed in a minority of eyes; most patients retained good vision at least in 1 eye.

Effect of resistance training during hemodialysis on circulating cytokines: a randomized controlled trial.

The purpose of this study was to evaluate the effect of a 12-week intradialytic progressive resistance training (PRT) regimen on circulating pro- and anti-inflammatory cytokines. Forty-nine patients (62.6 ± 14.2 years) were recruited from the outpatient hemodialysis unit of the St. George Public Hospital, Sydney, Australia. Patients were randomized to: PRT + usual care (n = 24) or usual care control (n = 25). The PRT group performed two sets of 10 exercises at high intensity using free-weights, 3 times per week for 12 weeks during dialysis, while the control group did not exercise. Tumor necrosis factor-alpha, interleukin-1b, interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-10, and interleukin-12 were measured in serum before and after the intervention period. Muscle cross-sectional area (CSA), intramuscular lipid, intermuscular adipose tissue, and subcutaneous and total thigh fat, evaluated via computed tomography of the non-dominant mid-thigh, were also collected at both time points. All cytokines were significantly elevated in the total cohort at baseline compared with normative data. There were no cytokine changes over time or between groups (p > 0.05). In secondary analyses pooling the groups, changes in logIL-6 and IL-8 were inversely related to changes subcutaneous thigh fat (p < 0.05) while changes in logIL-6 were also inversely related to changes in thigh muscle CSA, and total thigh fat (p < 0.03). These data suggest that 12 weeks of intradialytic progressive resistance training does not improve circulating pro- and anti-inflammatory markers. Further research is required to elucidate the implications and mechanisms of the relationships between IL-6 and IL-8 and body composition in ESRD.

Evidence-based guidelines for the nutritional management of adult kidney transplant recipients.

OBJECTIVE: The present article summarizes the key recommendations of the evidence-based guidelines developed for the nutritional management of adult kidney transplant recipients. BACKGROUND AND METHODS: Nutrition interventions play an important role in preventing and managing common health problems associated with renal transplantation such as obesity, hypertension, diabetes, and cardiovascular disease. Two sets of guidelines were developed by a working group of renal dietitians and nephrologists. They were subject to expert panel review, and public consultation by renal clinicians and consumers before final endorsement by 2 authorities in Australia--Caring for Australasians with Renal Impairment (CARI) and Dietitians Association of Australia (DAA). Protocol and rigor of guideline development were previously described and published in the Journal of Renal Nutrition, 2009. RESULTS AND OUTCOMES: These guidelines address 13 priority topics identified by the renal community and complement each other with different emphasis, from research translation to day to day clinical practice recommendations. The published guidelines are available to the public through web-access of CARI and DAA, and journal publications. Information includes the guidelines themselves with level of evidence stated, grading of recommendations, suggestions for clinical care, search strategy, background and summary of evidence, recommendations of other guidelines, practice recommendations, appendices of useful tools, and suggestions for audits and future research. CONCLUSIONS: Two sets of comprehensive evidence-based nutrition guidelines from CARI and DAA are now available to help improve health outcomes of adult kidney transplant recipients.

Investigation of skeletal muscle quantity and quality in end-stage renal disease.

AIM: A more precise understanding of the aetiology and sequelae of muscle wasting in end-stage renal disease (ESRD) is required for the development of effective interventions to target this pathology. METHODS: We investigated 49 patients with ESRD (62.6 +/- 14.2 years, 0.3-16.7 years on haemodialysis). Thigh muscle cross-sectional area (CSA), intramuscular lipid and intermuscular adipose tissue (IMAT) were measured via computed tomography as indices of muscle quantity (i.e. CSA) and quality (i.e. intramuscular lipid and IMAT). Additional health and clinical measures were investigated to determine associations with these variables. RESULTS: Age, energy intake, disease burden, pro-inflammatory cytokines, nutritional status, strength and functioning were related to muscle quantity and quality. Potential aetiological factors entered into forward stepwise regression models indicated that hypoalbuminaemia and lower body mass index accounted significantly and independently for 32% of the variance in muscle CSA (r = 0.56, P < 0.001), while older age and interleukin-8 accounted for 41% of the variance in intramuscular lipid (r = 0.64, P < 0.001) and body mass index accounted for 45% of the variance in IMAT (r = 0.67, P < 0.001). Stepwise regression models revealed that intramuscular lipid was independently predictive of habitual gait velocity and 6 min walk distance, while CSA was independently predictive of maximal isometric strength (P < 0.05). CONCLUSION: Ageing, poor nutritional status and elevated interleukin-8 are factors potentially contributing to the loss of muscle quality and quantity in ESRD. These deficits can predict functional impairments, with intramuscular lipid accumulation most closely related to decline of submaximal musculoskeletal performance (walking), and low muscle CSA most closely related to decline of maximal performance (peak isometric strength).

Development of evidence-based guidelines for the nutritional management of adult kidney transplant recipients.

OBJECTIVE: This article documents the development of evidence-based guidelines for the nutritional management of adult kidney transplant recipients. Dietary interventions play an important role in preventing and managing common post-transplant health problems, such as cardiovascular disease and diabetes. However, there are currently no comprehensive, evidence-based guidelines for the nutritional management of kidney transplant recipients. METHODS AND RESULTS: Thirteen guideline topics were identified, including obesity, diabetes, dyslipidemia, and bone disease, following broad consultation with clinicians and transplant recipients in Australia and New Zealand. A systematic review of the scientific literature was undertaken, the protocol for which is published in the Cochrane Library. The evidence was graded and synthesized, and evidence-based recommendations formulated consistent with National Health and Medical Research Council of Australia standards. A total of 119 scientific papers were assessed. CONCLUSION: There was no level I or II evidence to support any guideline; however, there was sufficient level III and IV evidence to support Grade C and D recommendations for six guideline topics. Experts from 18 transplant units in Australia and New Zealand were consulted to generate consensus-based recommendations for the remaining seven topics, using the Delphi method. Using evidence from a comprehensive literature search and expert opinion, guidelines that represent current best practice have been produced. These guidelines have been evaluated in transplant units throughout Australia and New Zealand and have been submitted to the Dietitians Association of Australia (DAA) and Caring for Australasians with Renal Impairment (CARI) for endorsement.

Randomized controlled trial of intradialytic resistance training to target muscle wasting in ESRD: the Progressive Exercise for Anabolism in Kidney Disease (PEAK) study.

BACKGROUND: To determine whether prolonged (24 weeks) intradialytic progressive resistance training (PRT) could counteract muscle wasting more effectively than short-duration training (12 weeks) in patients with end-stage renal disease. STUDY DESIGN: Randomized controlled trial. SETTING & PARTICIPANTS: 49 patients (age, 62.6 +/- 14.2 years; 0.3 to 16.7 years on hemodialysis therapy) were randomly assigned to PRT plus usual care for 24 weeks (24WK group) or a crossover control group that received usual care for the first 12 weeks, then PRT plus usual care for the latter 12 weeks (12WK group). INTERVENTION: Two sets of 10 free-weight PRT exercises were performed at a high intensity during routine thrice-weekly hemodialysis treatment under direct supervision. OUTCOMES & MEASUREMENTS: Primary outcomes include thigh muscle cross-sectional area by means of computed tomography and intramuscular lipid content estimated through attenuation. Secondary outcomes include muscular strength, exercise capacity, and C-reactive protein level. RESULTS: The 24WK group increased muscle cross-sectional area (+1.82 +/- 3.25 cm(2)) compared with losses in the 12WK group (-1.37 +/- 6.87 cm(2); relative effect size, 0.59; 95% confidence interval [CI], -0.27 to 6.65; P = 0.04). However, this outcome did not achieve the level of statistical significance required (P = 0.025) after Bonferroni correction for multiple primary outcomes. There was no significant change in intramuscular lipid content between groups (+0.19 +/- 1.32 versus +0.16 +/- 1.69 Hounsfield units in the 24WK and 12WK groups, respectively; P = 0.31). Log C-reactive protein level tended to decrease in the 24WK group compared with the 12WK group (relative effect size, -0.63; 95% CI, -0.27 [-0.54 to 0.00]; P = 0.05). The 24WK group improved muscular strength measures and exercise capacity throughout the trial. LIMITATIONS: Single geographic site used; no control group without exercise exposure; unblinded assessment of some secondary outcome measures. CONCLUSIONS: Prolonged intradialytic PRT did not significantly improve muscle cross-sectional area or intramuscular lipid content compared with a shorter duration of exercise. Future trials are required to more thoroughly investigate the clinical importance and magnitude of myogenic adaptations to PRT in this cohort.

Progressive resistance training during hemodialysis: rationale and method of a randomized-controlled trial.

Skeletal muscle wasting in patients receiving maintenance hemodialysis (HD) has been well documented. The rationale for prescribing progressive resistance training (PRT) in this cohort in an attempt to reverse this catabolism and induce a wide spectrum of physiological, functional, and psychological health-related adaptations is extremely strong. Unfortunately, the barriers to exercise adoption in this cohort are many, which may explain the persisting sedentariness of this population and the lack of widespread clinical programs such as are now commonplace in cardiac rehabilitation and pulmonary rehabilitation units. Current health care practices for HD patients do not address the negative health issues of inactivity and muscle wasting. Therefore, we conducted the first randomized-controlled trial to prescribe PRT during maintenance HD treatment. The purpose of this paper is to present the rationale and methodology that we utilized for implementing intradialytic PRT in a conventional outpatient HD clinic. Potential areas for modification of PRT regimens in this setting are also presented.

A preliminary study of Heavy Brilliant Blue G for internal limiting membrane staining in macular hole surgery.

CONTEXT: Surgical outcomes of vitrectomy for idiopathic macular hole using a "heavy" Brilliant Blue G (HBBG) solution for staining and removal of the internal limiting membrane (ILM). SETTINGS AND DESIGN: Prospective interventional case series conducted in a tertiary eye care hospital. MATERIALS AND METHODS: Nineteen patients (20 eyes) with idiopathic macular hole were enrolled to undergo vitrectomy with ILM peeling using HBBG. BBG dye was made heavy by mixing with 10% dextrose normal saline (DNS) solution in 2:1 ratio. The adequacy of ILM staining was noted intraoperatively. The closure rates of macular hole and visual improvement were recorded. Patients were followed up postoperatively on day 1, week 1, and subsequently at 1, 3, and 6 months, and every 6th month thereafter. STATISTICAL ANALYSIS: Wilcoxon signed-rank test was used; P < 0.05 was considered significant. RESULTS: Preoperative best-corrected visual acuity (BCVA) ranged from 20/1000 to 20/63 (median: 20/100). Intraoperatively, the ILM stained very well in all eyes, and was easily removed. All macular holes closed postoperatively. The mean follow-up was 6.15 ± 2 months (range: 4-10; median: 6 months). Final BCVA ranged from 20/20 to 20/80 (median: 20/40), amounting to a significant visual improvement (P = 0.0001). BCVA improved by 1-8 Snellen lines in 19 eyes (95%); 16 eyes (80%) improved by ≥2 lines; 13 eyes (65%) achieved a final BCVA of 20/40 or better. CONCLUSIONS: Addition of 10% DNS to BBG dye allowed good ILM staining with less dye during macular hole surgery, and provided excellent anatomic and visual outcomes.

Progressive exercise for anabolism in kidney disease (PEAK): a randomized, controlled trial of resistance training during hemodialysis.

Skeletal muscle wasting is common and insidious in patients who receive maintenance hemodialysis treatment for the management of ESRD. The objective of this study was to determine whether 12 wk of high-intensity, progressive resistance training (PRT) administered during routine hemodialysis treatment could improve skeletal muscle quantity and quality versus usual care. Forty-nine patients (62.6 +/- 14.2 yr; 0.3 to 16.7 yr on dialysis) were recruited from the outpatient hemodialysis unit of the St. George Public Hospital (Sydney, Australia). Patients were randomized to PRT + usual care (n = 24) or usual care control only (n = 25). The PRT group performed two sets of 10 exercises at a high intensity (15 to 17/20 on the Borg Scale) using free weights, three times per week for 12 wk during routine hemodialysis treatment. Primary outcomes included thigh muscle quantity (cross-sectional area [CSA]) and quality (intramuscular lipid content via attenuation) evaluated by computed tomography scan. Secondary outcomes included muscle strength, exercise capacity, body circumference measures, proinflammatory cytokine C-reactive protein, and quality of life. There was no statistically significant difference in muscle CSA change between groups. However, there were statistically significant improvements in muscle attenuation, muscle strength, mid-thigh and mid-arm circumference, body weight, and C-reactive protein in the PRT group relative to the nonexercising control group. These findings suggest that patients with ESRD can improve skeletal muscle quality and derive other health-related adaptations solely by engaging in a 12-wk high-intensity PRT regimen during routine hemodialysis treatment sessions. Longer training durations or more sensitive analysis techniques may be required to document alterations in muscle CSA.