Relationship between appetite and symptoms of depression and anxiety in patients on chronic hemodialysis.

OBJECTIVE: We aimed at evaluating the association between appetite and symptoms of depression and anxiety, cognitive dysfunction, fatigue, and comorbidities in patients on hemodialysis (HD). DESIGN: A cross-sectional study was conducted. SETTING: The study was conducted in an outpatient HD service of a tertiary level academic hospital. PATIENTS: A total of 90 patients on HD were evaluated for appetite (during the past week, how would you rate your appetite?), symptoms of depression (Beck Depression Inventory [BDI]) and anxiety (Hamilton Anxiety Rating Scale [HARS]), cognitive dysfunction (Mini Mental State Examination [MMSE]), and comorbidities (Charlson Comorbidity Index). MAIN OUTCOME MEASURE: Relationship between appetite and symptoms of depression and/or anxiety, cognitive dysfunction, and comorbidities was assessed. RESULTS: In 43 patients, the appetite was very good/good (group 1), in 22, it was fair (group 2), and in 25, it was poor/very poor (group 3). Mean and median BDI were significantly higher in group 3 as well as the percentage of patients with BDI ≥16. Mean and median HARS and the percentage of patients with HARS >13 were significantly higher in group 3. MMSE was significantly lower in group 3 as well as the percentage of patients with MMSE ≤23. Multiple linear regression analysis showed a dependence of appetite by age and BDI (P = .007 and P = .002, respectively). CONCLUSIONS: Anorexia is associated with older age and symptoms of depression in patients on HD.

Interventions to counteract anorexia in dialysis patients.

The treatment of anorexia in chronic hemodialysis patients is based on a therapeutic strategy which includes optimal dialysis dose (through daily or nocturnal dialysis), support of food intake (through nutritional counseling and oral nutritional supplements), counteractive action to anorexic agents (e.g., inflammatory cytokines and low levels of branched chain amino acids), stimulation of appetite (ghrelin), and attention to associated symptoms (e.g., symptoms of depression and anxiety, fatigue, other comorbidities). However, the fact remains that the studies so far conducted are insufficient both in terms of number and quality to provide guidelines for clinical and research purposes. Randomized, controlled trials are needed in the future to define the best strategy to counteract anorexia in maintenance dialysis patients.

Appetite and gastrointestinal symptoms in chronic hemodialysis patients.

OBJECTIVE: The aim of the present cross-sectional study was to assess the association between self-reported appetite and gastrointestinal symptoms in chronic hemodialysis patients. DESIGN: A cross-sectional study was carried out. SETTING: The study was carried out at an outpatient hemodialysis service center. PATIENTS: A total of 110 patients were included in this study. INTERVENTION: The first question of the Hemodialysis Study Appetite questionnaire was used to assess the appetite of the HD patients. The multiple-choice answers for the first question "During the past week, how would you rate your appetite?" were as follows: (1) very good, (2) good, (3) fair, (4) poor, or (5) very poor. At the same time, each patient was invited to answer the following questions: Did you have any of the following symptoms (hiccups, feeling full after a few bites of food, nausea, vomiting, indigestion, abdominal pain, bloating, and constipation) in the last 2 weeks? Are there particular foods that you used to like but now do not? Did you have changes in smell in the last 2 weeks? Did you have taste changes in the last 2 weeks? MAIN OUTCOME MEASURE: Possible associations between appetite and gastrointestinal symptoms were assessed in this study. RESULTS: In 52 (47.2%) HD patients, the appetite was very good or good (group A), in 28 (25.4%) fair (group B), and in 30 (27.3) poor or very poor (group C). The most frequent symptoms were bloating and constipation. The frequency of food aversion and early satiety were 23.6% and 18.2%, respectively. The frequency of changes in smell and taste were 3.6% and 7.2%, respectively. The frequency of early satiety, food aversion, changes in smell and taste was significantly higher in group C as compared with group A. Similarly, the frequency of early satiety, food aversion, and changes in taste were higher in group B than in group A. The other frequencies did not differ significantly among group A, B, and C. CONCLUSION: Food aversion, early satiety, changes in taste and smell were significantly more frequent in HD patients with poor or very poor appetite as compared with those with good or very good appetite.

Artificial nutritional support in chronic hemodialysis patients: a narrative review.

OBJECTIVE: Malnutrition is common in hemodialysis (HD) patients and is a powerful predictor of morbidity and mortality. While much progress has been made in identifying the causes and pathogenesis of malnutrition in patients on HD, no consensus has been reached on its management. Nutritional counseling, appetite stimulants, growth hormone, androgenic anabolic steroids, and anti-inflammatory drugs have been tested with contradictory and nonconclusive results. Oral nutritional supplements (ONSs) and intradialytic parenteral nutrition (IDPN) also have been studied. DESIGN/SETTING/PATIENTS: We searched the MEDLINE and PubMed databases for randomized clinical trials, comparative nonrandomized clinical trials, studies with patients who were controls for themselves, and single-arm studies on ONS and IDPN. Thirty-four studies (3223 patients) have been identified and analyzed. Seventeen studies were on ONS (778 patients) and 17 were on IDPN (2475 patients). RESULTS: ONS may improve serum albumin levels and/or other nutritional parameters, whereas there are insufficient data on clinical outcome. IDPN improves serum albumin and body weight. CONCLUSION: Data on survival are conflicting but the only study with an adequate population sample shows that IDPN does not influence survival. Randomized, controlled studies are needed to clarify the role of ONS and IDPN in the treatment of malnutrition in HD.

Anorexia, fatigue, and plasma interleukin-6 levels in chronic hemodialysis patients.

This study aimed at evaluating the possible relationship between anorexia and fatigue in hemodialysis (HD) patients and at measuring the plasma levels of interleukin-6 (IL-6) and C-reactive protein (CRP) in HD patients with or without anorexia and/or fatigue. The first question of the Hemodialysis Study Appetite questionnaire was used to assess the appetite of the HD patients and the vitality scale of the SF-36 to assess fatigue. The Charlson Comorbidity Index was assessed in each patient. Seventy-six HD patients were studied. Forty-four were males and 32 females. Thirty-two were classified as not-anorexic and not-fatigued, 12 as not-anorexic but fatigued, 6 as anorexic and not-fatigued, and 26 as anorexic and fatigued. Plasma IL-6 levels (pg/mL) were significantly higher in anorexic and fatigued patients (10.9 ± 11.9) than in not-anorexic and not-fatigued (1.6 ± 0.6) (p < 0.001) and in anorexic but not-fatigued patients (1.8 ± 1.7) (p < 0.01). With respect to not-anorexic but fatigued patients (3.1 ± 1.5), the difference was not statistically significant (p = 0.058). The plasma CRP levels (mg/dL) also were significantly higher in anorexic and fatigued patients (9.2 ± 6.3) than in not-anorexic and not-fatigued patients (4.1 ± 4.5), in anorexic but not-fatigued patients (2.5 ± 1.6), and in not-anorexic but fatigued patients (4.1 ± 4.4) (p = 0.001). The presence of both anorexia and fatigue in chronic HD patients is associated with significantly higher levels of plasma IL-6 and CRP and a higher frequency of comorbidities.

[Ultrasound parameter-based response to treatment with new drugs for secondary hyperparathyroidism: a retrospective analysis in a single dialysis center]. / Risposta terapeutica ai nuovi farmaci dell'iperparatiroidismo secondario in relazione al grado ecografico di iperplasia paratiroidea: analisi retrospettiva in un singolo centro dialisi.

In hemodialysis patients with secondary hyperparathyroidism (SHPT) ultrasonography of the parathyroid glands allows to assess the glandular growth and to define the limits of medical treatment. The present retrospective study evaluated the relationship between parathyroid gland hyperplasia and the effectiveness of new drugs. Fifty-three patients with SHPT (iPTH > 400 pg/mL) after treatment with oral calcitriol were included in the study. These patients underwent parathyroid ultrasonography and sequential therapy with intravenous calcitriol (first step), paracalcitol (second step), and paracalcitol + cinacalcet (third step). Patients with median PTH < 300 pg/mL during the period of therapy and follow-up were considered responders. The therapeutic response was correlated with ultrasound parameters (number of parathyroid glands, maximum longitudinal diameter, structural score, and vascular score). Four (10%) of 41 patients treated with IV calcitriol, 7 (27%) of 26 patients treated with paracalcitol, 7 (41%) of 17 patients treated with cinacalcet and paracalcitol, and 1 (20%) of 5 patients treated with cinacalcet alone were responders. ROC curve analysis showed that maximum longitudinal diameter (< 9 mm), number of parathyroid glands (< -1), structural score (< 2), and vascular score (< 2) predicted response to any treatment. New drugs (paracalcitol, cinacalcet) are more effective in SHPT than conventional ones. However, the traditional ultrasonographic cutoff for the efficacy of medical therapy remained unchanged. Thus parathyroid gland ultrasonography predicts the therapeutic response also to the new drugs.

Ageing of patients on chronic dialysis: effects on mortality--a 12-year study.

BACKGROUND: During the last few decades the mean age of subjects on chronic dialysis (CD) significantly increased. The effects of these changes on mortality rates, causes of death, early and long-term predictors for mortality have not yet been clarified. We analysed this issue through a study performed over a period of 12 years. METHODS: We studied 8977 patients enrolled on the Lazio Dialysis Registry (Italy) in 1995-2006. We analysed annual mortality rates, causes of death, probability and determinants of the survival. RESULTS: The overall mortality rate was 14.6 deaths (95% CI: 14.2-14.9) per 100 person-years on CD, remaining essentially unchanged over the 12-year period, despite a 5-year increase in the median age. A reduction in mortality was found for patients >74 years from 29.8 (95% CI: 24.8-34.9) in 1995 to 22.5 (95% CI: 20.0-25.1) in 2006. No statistically significant differences were found over time in annual mortality rates by cause of death. The probability of survival was 0.86 1 year after starting dialysis and 0.33 after 12 years. We found a higher association between haematocrit levels, serum albumin, self-sufficiency and survival within 1 year of dialysis and between diabetes and survival after 1 year. CONCLUSIONS: The finding that the mortality rate of CD patients did not change over the last 12 years, despite concomitant and significant ageing of patients, supports the public health policy of providing CD to very old subjects. The identification of the clinical factors that predict survival underlines the role of clinicians in preventing and treating these conditions after the start of CD.

Body mass index, comorbid conditions and quality of life in hemodialysis patients.

INTRODUCTION: Few studies have evaluated the prevalence of comorbid conditions, as well as the health-related quality of life (HRQL), in hemodialysis (HD) patients stratified according to body mass index (BMI), and these have led to conflicting results. We compared the prevalence of comorbidities and HRQL in HD patients stratified according to BMI. METHODS: One hundred and twelve HD patients were stratified into 4 groups according to the BMI: underweight (<18.5), normal-weight (18.5-24.9), overweight (25.0-29.9) and obese (>or=30). Medical conditions enabling computation of the Charlson Comorbidity Index and HRQL were assessed through the SF-36 questionnaire. RESULTS: There were 3 underweight (excluded from the analysis), 58 normal weight, 33 overweight and 18 obese patients. There were 68 males and 41 females. In obese patients, compared with overweight and normal-weight patients, there were significantly higher prevalences of hypertension (88.8% vs. 66.6% vs. 31%; p<0.001), diabetes (33.3% vs. 9.1% vs. 3.4%; p=0.001), coronary disease (61.1% vs. 36.3% vs. 31%; p=0.001) and cerebrovascular disease (50% vs. 21.2% vs. 22.4%; p=0.04). The prevalences of other comorbidities were similar in the 3 groups. Similarly, the Charlson Comorbidity Index was significantly higher in obese than in overweight and normal-weight patients (p=0.02). In the SF-36, there was a trend for the obese subjects to score lower than normal-weight patients on the bodily pain and role emotional scales. With regard to the physical functioning scale and the physical component summary score, the difference was statistically significant. Obese HD patients did not score significantly lower on the scale related to mental health. CONCLUSIONS: The present study showed that obese patients have a higher prevalence of some comorbidities and score lower on physical functioning scale and on the physical component summary of the SF-36 instrument.

Fatigue and its correlates in chronic hemodialysis patients.

BACKGROUND: The present study aimed at evaluating the possible correlation between fatigue and demographic, clinical and laboratory variables in chronic HD patients. METHODS: Sixty-two chronic HD patients were assessed for the presence of fatigue through the SF-36 Vitality subscale and were administered the Beck Depression Inventory (BDI), the Hamilton Anxiety Rating Scale (HARS), and the Mini-Mental State Examination. In all, the number/severity of comorbidities was assessed through the Charlson Comorbidity Index and laboratory parameters were measured. RESULTS: Correlations among the SF-36 Vitality subscale and age, dialytic age, BDI, HARS and the Charlson Comorbidity Index were statistically significant. Correlations between the SF-36 vitality score and the serum creatinine, albumin and IL-6 levels were also significant. Twenty-six and 36 patients constituted the fatigued and nonfatigued groups, respectively. The age and the scores of the Charlson Comorbidity Index, BDI and HARS of fatigued patients were significantly higher than those of nonfatigued subjects. Serum IL-6 levels were significantly higher in the fatigued than in the nonfatigued group, whereas serum albumin and creatinine levels were significantly lower. CONCLUSIONS: We found that depression, anxiety, number and severity of comorbidities and IL-6 levels are significantly correlated with fatigue in end-stage renal disease patients receiving chronic hemodialysis.

Mechanisms and treatment of anorexia in end-stage renal disease patients on hemodialysis.

Anorexia, defined as the loss of the desire to eat, is relatively common in hemodialysis patients, occurring in one third of such cases. The pathogenesis is essentially unknown. It has been proposed that uremic toxins such as middle molecules, inflammation, altered amino acid pattern, leptin, ghrelin, and neuropeptide Y are involved. Anorexia reduces oral energy and protein intakes, thus contributing to the development of malnutrition and cachexia. Unquestionably, it contributes to poor quality of life. The clinical relevance of anorexia as an independent prognostic factor in hemodialysis is debated. The treatment of this debilitating condition is based on a therapeutic strategy that may include daily dialysis sessions and nutritional counseling. Normalization of plasma branched chain amino acids through branched chain amino acid supplementation may decrease anorexia and improve energy and protein intake. The role of megestrol acetate as an appetite stimulant needs to be validated through adequate randomized trials. Subcutaneous ghrelin administration and melanocortin-receptor antagonists appear to be promising therapeutic interventions.

Appetite in chronic hemodialysis patients: a longitudinal study.

OBJECTIVE: In hemodialysis (HD) patients, appetite behavior over time and the causes of diminished appetite are essentially unknown. The present study aimed to assess appetite over time in HD patients, and to define the factors associated with different appetite trends. DESIGN: We conducted a longitudinal study. SETTING: This study took place at the Hemodialysis Service of the Catholic University of the Sacred Heart of Rome, Italy. PATIENTS: We studied 54 HD prevalent patients. INTERVENTION: At baseline and 5 months later, we assessed appetite, nutritional and inflammatory parameters, comorbid conditions, and scores on the Charlson Comorbidity Index. MAIN OUTCOME MEASURE: We were primarily interested in an evaluation of appetite over time and the definition of factors associated with different appetite trends. RESULTS: We identified 5 groups of patients. In group A (15 patients), every month, each patient responded that appetite was very good or good. In group B (10 patients), every month, each patient responded that appetite was good or fair. In group C (6 patients), every month, each patient responded that appetite was fair or poor. In group D (6 patients), every month, each patient responded that appetite was poor or very poor. In group E (17 patients), the answers of each patient varied over time. Groups A and B were pooled into group 1, groups C and D into group 2, and group E constituted group 3. Age was significantly lower in group 1 than in groups 2 and 3. Comorbidities were significantly more frequent in groups 2 and 3 than in group 1. The Charlson Comorbidity Index was significantly higher in groups 2 and 3 than in group 1. The percentage of patients hospitalized during follow-up and the number of hospitalizations were significantly higher in groups 2 and 3 than in group 1. CONCLUSIONS: Appetite in HD patients may be constantly very good/good or fair/poor, or may fluctuate over time. The latter trends are associated with older age, more comorbidities, and more hospitalizations.

Anorexia and plasma levels of free tryptophan, branched chain amino acids, and ghrelin in hemodialysis patients.

OBJECTIVE: The aim of the present cross-sectional study was to assess appetite and to examine at the same time the associations between self-reported appetite and orexigen (ghrelin) and anorexigen (free tryptophan, free tryptophan/large neutral amino acid ratios, low branched chain amino acid levels) substances in chronic hemodialysis patients. DESIGN: Cross-sectional study. SETTING: Patients were recruited from the Catholic University Outpatient Dialysis Clinic. PATIENTS: A total of 59 patients (32 men and 27 women) were included in this study. The mean age was 63.7 +/- 13.9 years, and the mean dialytic age was 6.6 +/- 5.1 years. Their mean body mass index of the study population was 25.1 +/- 4.1 kg/m(2). METHODS: The first question of the Hemodialysis (HEMO) Study Appetite questionnaire was used to assess the appetite of the hemodialysis patients. The multiple-choice answers for the first question, "During the past week, how would you rate your appetite?" were (1) very good, (2) good, (3) fair, (4) poor, or (5) very poor. Plasma amino acid concentrations were measured with the use of liquid chromatography. Ghrelin levels were measured with Ghrelin-RIA (Mediagnost). RESULTS: According to the questionnaire, in 16 of 59 (27.1%) hemodialysis patients, their appetite was very good (group 1); in 15 (25.4%), it was good (group 2); in another 15 (25.4%), it was fair (group 3); in 10 (16.9%), it was poor; and in 3 (5%), it was very poor. For statistical purposes, patients with a poor or very poor appetite were pooled together into a single group (group 4). Body mass index and serum albumin were significantly lower in patients with a fair and poor/very poor appetite than in patients with a very good or good appetite. According to the Subjective Global Assessment, all patients in groups A and B were well-nourished, whereas most patients in groups C (60%) and D (68%) were severely malnourished. Most of the comorbid conditions were significantly higher in patients of groups C and D. Branched chain amino acids were significantly lower in patients with a fair or poor/very poor appetite with respect to patients with a very good or good appetite. Free tryptophan levels were similar in the four groups of patients. The molar sum in plasma of the other large neutral amino acids (valine, leucine, isoleucine, tyrosin, phenylalanine) (large neutral amino acids) tended to be lower in patients with a fair and poor/very poor appetite than in patients with a very good or good appetite. However, the free tryptophan/large neutral amino acid ratio did not change significantly according to the appetite reported by the patients. Mean ghrelin levels were significantly higher in patients of group D than in other groups and in patients of groups B and C than in patients of group A. CONCLUSIONS: The present study shows that poor appetite is associated with significantly lower branched chain amino acid levels but not with higher free tryptophan levels and higher free tryptophan/large neutral amino acid ratios in hemodialysis patients. In addition, significantly higher levels of ghrelin have been observed in patients with a poor/very poor appetite.

Serum albumin, body weight and inflammatory parameters in chronic hemodialysis patients: a three-year longitudinal study.

BACKGROUNDS AND AIMS: The present study aimed at making prospective longitudinal measurements of nutritional and inflammatory parameters to determine whether nutritional and inflammatory status decline or increase over time in a cohort of prevalent hemodialysis patients, and to evaluate which factors influence eventual changes. PATIENTS: 64 hemodialysis patients were followed at 0, 3, 6, 9, 12, 15, 18, 21, 24, 27, 30, 33, and 36 months. At each follow-up visit, dry body weight, serum albumin, serum total cholesterol, total white blood cells, total lymphocyte count, serum glucose, C-reactive protein, ferritin, fibrinogen, hemoglobin, and weekly erythropoietin dose were assessed. MAIN OUTCOME MEASURES: Changes in nutritional and inflammatory parameters over time. RESULTS: 43 patients completed the study at 36 months. Mean serum albumin levels (g/dl) improved significantly between baseline (3.76 +/- 0.24) and 36 months (3.93 +/- 0.27) (F = 4.005; p = 0.0009). Dialytic age was significantly associated with changes of serum albumin (F = 2.797; p = 0.028). The mean dry weight slightly remained stable over time (F = 1.473; p = 1.0) as well as the level of total cholesterol (p = 0.77) and lymphocyte count (F = 1.539; p = 0.186). Over time, the levels of C-reactive protein tended to decrease, although the differences were not statistically significant (F = 1.332; p = 0.19). Over time, the serum level of fibrinogen (F = 0.422; p = 0.17) and ferritin (F = 0.314; p = 0.52) remained stable. The number of white blood cells significantly decreased over time (F = 4.691; p = 0.0079) and dialytic age (F = 3.214; p = 0.015) was the variable significantly associated with such decline. The hemoglobin levels (F = 1.423; p = 0.14) and the weekly erythropoietin dose did not change significantly during the study (F = 1.019; p = 0.61), nor did the serum glucose levels (F = 1.231; p = 0.10). CONCLUSION: These results support the hypothesis that end-stage renal disease and HD are not necessarily associated with deterioration of the nutritional status over time.

Ultrasound patterns of parathyroid glands in chronic hemodialysis patients with secondary hyperparathyroidism.

BACKGROUND: The role ofparathyroid glands (PTG) ultrasonography (US) in hemodialysis patients with secondary hyperparathyroidism (SHPT) is still controversial. The present study aimed at evaluating the relationship between US findings and SHPT degree as well as therapeutic outcome. METHODS: Twenty hemodialysis patients with moderate SHPT and 15 with severe SHPT underwent US to assess the PTG number, maximum longitudinal diameter (MLD), structural (1-hypoechoic, 2-slight heterogeneous, 3-high heterogeneous, 4-nodular) and vascular patterns (1-slight, 2-medium and 3-high). RESULTS: PTG number, MLD and US patterns were correlated with iPTH levels. MLD of patients with moderate or severe SHPT was 7.2 +/- 2.3 and 15 +/- 5.1 mm (p < 0.001). Most patients with moderate SHPT showed a single PTG with an MLD <9 mm associated with 1-2 structural and vascular pattern, whereas patients with severe SHPT exhibited more than one PTG with MLD >9 mm and 3-4 structural and vascular patterns. Thirteen patients were responders to treatment and 22 nonresponders. In nonresponders, a higher number of PTG was observed as well as higher echostructural and vascular patterns. In 14 patients who underwent parathyroidectomy, no differences were found between PTG US MLD and pathology diameter. All PTG with evidence of 3-4 structural and vascular score at ultrasound showed nodular hyperplasia at pathological examination. CONCLUSIONS: The adopted classification of US findings is correlated with SHPT degree and therapeutic outcome and might be an adjunctive predictive method useful to assess the SHPT severity and to plan the therapeutic strategy.

Is regression of left ventricular hypertrophy in maintenance hemodialysis patients possible?

Left ventricular hypertrophy (LVH), present in 70-80% of patients at the start of dialysis, results from chronic high blood pressure, volume overload, or both, in association with a number of metabolic and neurohumoral alterations. LVH is associated with poor outcome and was considered irreversible until the end of the 20th century. Conversely, in recent years, numerous studies have been published demonstrating that LVH may regress through various therapeutic strategies such as prevention and control of anemia, control of volume load, use of antihypertensive drugs, use of daily or nocturnal hemodialysis (HD), prevention and treatment of hyperphosphatemia, administration of vitamin D or with multifactorial interventional approaches. However, it must be emphasized that most of these studies have included a small number of patients, that many are single-arm and that few are randomized and controlled. In general, it seem that further, adequate, randomized, controlled studies are warranted to better define the optimal therapeutic approach to treat LVH in end-stage renal disease patients receiving chronic HD.

Body mass index and cardiovascular risk factors and biomarkers in hemodialysis patients.

BACKGROUND: Being overweight and obesity are associated with improved survival in hemodialysis (HD) patients, based on mechanisms that are presently uncertain. We compared traditional and uremia-related cardiovascular risk factors in HD patients stratified according to their body mass index (BMI). METHODS: One hundred sixteen HD patients were stratified into 4 groups according to the BMI: underweight (<18.5), normal weight (18.5-24.9), overweight (25.0-29.9) and obese (> or =30). Blood samples were obtained before the HD session to measure serum albumin, high-sensitivity C-reactive protein, fibrinogen, ferritin, total cholesterol, LDL cholesterol, HDL cholesterol, apolipoprotein A-I and apolipoprotein B-100, apolipoprotein B (apoB) to apolipoprotein A (apoA) ratio and Lp(a) lipoprotein. RESULTS: There were 3 underweight (excluded from the analysis), 58 normal weight, 35 overweight and 20 obese patients. Their mean age was 62.1 +/- 14.1 years. There were 68 men and 45 women. Mean dialytic age was 5.32 +/- 3.2 years. The mean BMI of the study population was 25.2 +/- 4.1. The prevalence of smoking habit was similar in the 3 groups (17.2%, 8.5% and 25%, respectively; p=0.28). The prevalence of hypertension was higher in overweight (77.1%) and obese (65%) patients than in leaner counterparts (53.4%), although the difference was not significant. Conversely, diabetes prevalence was significantly higher in overweight and obese patients (22.8% and 30%, respectively) than in normal weight patients (6.9%; p=0.02). The serum levels of total cholesterol, HDL cholesterol, LDL cholesterol, Lp(a) lipoprotein, apolipoprotein A-I, apolipoprotein B-100, and apoA/apoB ratio were similar in the 3 BMI groups. Triglycerides levels were significantly higher in obese (221.2 +/- 132.7 mg/dL) and overweight (230.5 +/- 119.3 mg/dL) patients than in those of normal weight (154.6 +/- 78.8 mg/dL; p=0.02). Most of the uremia-related cardiovascular risk factors (anemia, hyperparathyroidism, chronic inflammation) were comparable among BMI categories as well as the levels of C-reactive protein, fibrinogen and ferritin. CONCLUSION: The present study suggests that almost all traditional and uremia-related cardiovascular risk factors do not differ significantly among different categories of BMI in hemodialysis patients.

Cultural comparison of symptoms in patients on maintenance hemodialysis.

Although symptoms are common and frequently severe in patients on maintenance hemodialysis, little is known about the relationship between cultural background and symptom burden. The aim of this study was to explore differences in the prevalence and severity of symptoms between American and Italian hemodialysis patients. We administered the 30-item Dialysis Symptom Index to American and Italian patients receiving maintenance hemodialysis during routine dialysis sessions. The prevalence and severity of individual symptoms were compared between patient populations, adjusting for multiple comparisons. Multivariable logistic regression and ordinal logistic regression were used to assess the independent associations of cultural background with the prevalence and severity of symptoms, respectively. We enrolled 75 American and 61 Italian patients. American patients were more likely to be black (36% vs. 0%, P<0.001) and diabetic (53% vs. 13%, P<0.001). Italian patients were more likely to report decreased interest in sex, decreased sexual arousal, feeling nervous, feeling irritable, and worrying (P<0.001, respectively). Adjustment for demographic and clinical variables had no impact on these cultural differences in symptom prevalence. The median severity of 11 symptoms including muscle soreness, muscle cramps, and itching was greater among Americans (P<0.001, respectively), although nearly all of these differences were rendered nonstatistically significant with adjustment for race, diabetes, and/or Kt/V. Italian patients receiving chronic hemodialysis report a greater burden of symptoms than American patients, particularly those related to sexual dysfunction and psychosocial distress. These findings suggest that cultural background may affect adaptation to chronic hemodialysis therapy.

Long-term oral sodium bicarbonate supplementation does not improve serum albumin levels in hemodialysis patients.

Metabolic acidosis, a frequent event in hemodialysis patients, has been implicated as a potential cause of protein-energy malnutrition. Unfortunately, correction of metabolic acidosis by means of high bicarbonate concentration in the dialysate does not seem to lead to significant changes in nutritional parameters. The project was a single-arm, open-label, 12-month pilot study at a university-based tertiary care center aimed at evaluating whether correction of metabolic acidosis through long-term oral sodium bicarbonate supplementation improves serum albumin levels and other nutritional parameters in patients undergoing maintenance hemodialysis. Twenty highly acidotic hemodialysis patients patients were invited to consume an oral supplementation of sodium bicarbonate (1 g, thrice daily), for 12 months. Patients were followed at baseline and every month, until month 12. At each follow-up visit, dry body weight, BMI, blood pressure, presence of edema, venous bicarbonate, and serum albumin were measured. Total lymphocyte count, fasting total cholesterol and C-reactive protein were assessed every 2 months. At baseline and at 12 months, the subjective global assessment of nutritional status and the protein equivalent of nitrogen appearance normalized to actual body weight were determined. Plasma bicarbonate level rose from 18.1 +/- 2.7 to 22.1 +/- 4.5 mmol/l after 10 months (p = 0.001). Mean serum albumin levels were 3.8 +/- 0.2 mg/dl at baseline and 3.9 +/- 0.2 at the end of the study. Repeated measure ANOVA showed that there was no significant effect of bicarbonate treatment on serum albumin levels (p = 0.29), dry weight (p = 0.1), serum total cholesterol (p = 0.97), total lymphocyte count (p = 0.69), or C-reactive protein (p = 0.85). Mean subjective global assessment score was 4.53 +/- 0.37 at baseline and 4.58 +/- 0.54 at 12 months (p = 0.1). Mean nPNA (g/kg/day) was 0.86 +/- 0.05 at baseline and 0.85 +/- 0.08 at month 12. The present study demonstrates that long-term oral sodium bicarbonate at the dose of 1 gram thrice daily has no significant effect on nutritional status of HD patients.

Oxidized low-density lipoprotein biomarkers in patients with end-stage renal failure: acute effects of hemodialysis.

OBJECTIVE: To assess the effect of end-stage renal failure on oxidized low-density lipoprotein (OxLDL) biomarkers and the acute effects of hemodialysis. Oxidized phospholipids (OxPL) on apolipoprotein B-100 (apoB) particles (OxPL/apoB) have been associated with cardiovascular disease and new cardiovascular events. Patients with end-stage renal failure have increased oxidative stress and are at significantly increased risk of cardiovascular disease. METHODS AND RESULTS: Fifty-two stable patients with end-stage renal failure undergoing chronic hemodialysis were included in the study. Pre and post hemodialysis blood samples were obtained for measurement of OxLDL biomarkers: oxidized phospholipids (OxPL) on apolipoprotein B-100 (apoB) particles (OxPL/apoB) measured by antibody E06, IgG and IgM autoantibody titers to copper-oxidized LDL (Cu-OxLDL) and malondialdehyde (MDA)-LDL, IgG and IgM apolipoprotein B-100-immune complexes (IC/apoB). Traditional laboratory variables as well as C-reactive protein (CRP) and lipoprotein(a) [Lp(a)] were also measured. For the baseline variables, the distribution of OxPL/apoB and Lp(a) were skewed to lower values, and a strong correlation was noted between OxPL/apoB and Lp(a) (r = 0.94, p < 0.0001). No major associations were noted between OxLDL biomarkers and age, gender or dialytic age. There were also no correlations between OxLDL biomarkers and traditional risk factors, CRP, body mass index, serum creatinine, hypertension or intravenous iron therapy. Following dialysis, there as a significant reduction in OxPL/apoB (-7.5%, p = 0.048) and triglyceride levels (-10.8%, p = 0.005). All other OxLDL biomarkers, CRP, total cholesterol, LDL-C, HDL-C and apoB-100 increased significantly (range 6.3-26.9%, p value range 0.005 to <0.0001). Total protein plasma levels increased 8.8% (p = 0.014 compared to predialysis) following dialysis, consistent with a hemoconcentration effect of hemodialysis. CONCLUSION: In end-stage renal failure patients undergoing hemodialysis, a reduction in OxPL/apoB levels was noted, despite the hemoconcentrating and strong pro-oxidant milieu of hemodialysis. Studies in larger populations of end-stage renal failure patients are needed to assess whether these findings predict future clinical outcomes.

Risks of using internal thoracic artery grafts in patients in chronic hemodialysis via upper extremity arteriovenous fistula.

BACKGROUND: In patients in chronic hemodialysis via upper extremity arteriovenous fistula in whom ipsilateral internal thoracic artery graft was used for myocardial revascularization, hemodynamic interference between the fistula and the graft during dialysis can be hypothesized. METHODS AND RESULTS: In 5 patients undergoing chronic hemodialysis via upper extremity arteriovenous fistula, ipsilateral to an internal thoracic to left anterior descending graft mammary flow was studied by means of transthoracic echo-color Doppler at baseline and during hemodialysis. Flow in the contralateral mammary artery was used as control. Transthoracic echocardiography was performed in concomitance with flow evaluation to assess eventual modifications of left ventricular segmental wall motion. Immediately after hemodialysis pump start there was a marked reduction of peak systolic and end-diastolic velocities and time average mean velocity and flow in the ITA ipsilateral to the fistula, whereas no substantial hemodynamic modification was evident in the contralateral artery. Dialysis-induced reduction of ipsilateral ITA flow was accompanied by evidence of hypokinesia of the anterior left ventricular wall. Three cases also experienced clinical angina. CONCLUSIONS: Hemodynamically evident flow steal and consequent myocardial ischemia develop during hemodialysis in patients with upper extremity arteriovenous fistula and ipsilateral internal thoracic artery to coronary graft. These data have major implications for patients' management, both for nephrologists and cardiac surgeons.