RESUMEN
With over 100 trillion microbial cells, the gut microbiome plays important roles in both the maintenance of health and the pathogenesis of disease. Gut microbiome dysbiosis, resulted from alteration of composition and function of the gut microbiome and disruption of gut barrier function, is commonly seen in patients with chronic kidney disease (CKD). The dysbiotic gut microbiome generates excessive amounts of uremic toxins, and the impaired intestinal barrier permits translocation of these toxins into the systemic circulation. Many of these uremic toxins have been implicated in the progression of CKD and increased cardiovascular risk. Various therapeutic interventions have been proposed that aim to restore gut microbiome symbiosis. If proven effective, these interventions will have a significant impact on the management of CKD patients. In this review, we discuss the consequences of gut microbiome dysbiosis in the context of CKD, discuss the consequences of gut dysbiosis, and highlight some of the recent interventions targeting the gut microbiome for therapeutic purposes.
Asunto(s)
Microbioma Gastrointestinal , Insuficiencia Renal Crónica , Animales , Enfermedades Cardiovasculares , Progresión de la Enfermedad , Humanos , Insuficiencia Renal Crónica/tratamiento farmacológico , Factores de RiesgoRESUMEN
BACKGROUND/OBJECTIVE: Recent epidemiological data have shown that abdominal fat accumulation is associated with increased risk of cardiovascular events in patients with chronic kidney disease (CKD). This study aimed to investigate the association between visceral adiposity and coronary artery calcification (CAC) in CKD patients. SUBJECTS/METHODS: Cross-sectional study with 65 nondialyzed CKD male patients (59 ± 9 years, CKD stages 3 and 4). Abdominal fat compartments were assessed by computed tomography (CT) at L4-L5 level. Visceral to subcutaneous (V/S) fat ratio was calculated. Visceral obesity was defined as a V/S fat ratio greater than the median value of the sample study (>0.55). CAC was detected by multi-slice CT. CAC scores were calculated with the Agatston method. RESULTS: CAC was present (calcium score >10 AU) in 66% of patients. In the group with visceral obesity, the CAC score was significantly higher. This group had lower adiponectin and higher leptin levels compared to patients without visceral obesity. In the whole sample, higher V/S fat ratio was associated with CAC score, independently of age, body mass index, diabetes, ionized calcium, smoking or renal function. CONCLUSION: Our results show an association between visceral obesity and CAC in CKD patients, suggesting a deleterious effect of visceral fat in these patients. Increased visceral adiposity might enhance cardiovascular risk in this particular population.
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Adiposidad , Enfermedad de la Arteria Coronaria/etiología , Grasa Intraabdominal/patología , Obesidad Abdominal/complicaciones , Insuficiencia Renal Crónica/fisiopatología , Calcificación Vascular/etiología , Anciano , Biomarcadores , Pesos y Medidas Corporales , Brasil/epidemiología , Estudios de Cohortes , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/epidemiología , Enfermedad de la Arteria Coronaria/fisiopatología , Estudios Transversales , Hospitales Universitarios , Humanos , Grasa Intraabdominal/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Obesidad Abdominal/diagnóstico por imagen , Servicio Ambulatorio en Hospital , Prevalencia , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/patología , Índice de Severidad de la Enfermedad , Tomografía Computarizada por Rayos X , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/epidemiología , Calcificación Vascular/fisiopatologíaRESUMEN
BACKGROUND: Chronic groin pain is defined as pain arising 3-6 months after inguinal hernia repair that can compromise the patient's quality of life. Many articles in the literature report clinical presentation, but there are no well-defined indications and protocols of treatment. METHODS: Forty-six patients underwent surgical treatment for chronic groin pain that consisted of a simultaneous double approach, anterior and posterior, to the inguinal region, with 44 triple neurectomies and 2 iliohypogastric neurectomies. Ilio-inguinal and ilio-hypogastric nerves were resected by anterior approach, while genitofemoral trunk was resected by a posterior pre-peritoneal approach. Mesh was removed in 24 cases, and mesh and plug were removed in 16 cases. A new mesh repair was performed in 42 cases. All the patients were examined 1 week, 1 month and 1 year postoperatively. RESULTS: In 40 patients, the surgical treatment has obtained good response with improvement or complete resolution of the pain. Two patients referred persistent groin pain different from preoperative and in 4 cases the pain persisted without substantial benefit. Mean VAS value was 7.89 before surgery and 1.89 after surgery. CONCLUSIONS: Choice of the adequate therapy of chronic groin pain after inguinal hernia repair is still controversial. Our surgical approach turned out to be a safe and effective procedure. In this way, an accurate exploration of the whole inguinal region can be performed along with the identification of the nerves involved. Anyway in a certain number of cases, the resolution of pain cannot be achieved; this suggests a possible involvement of differences in the single personality and tolerances of pain in the different patients.
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Dolor Crónico/cirugía , Herniorrafia/efectos adversos , Dolor Postoperatorio/cirugía , Mallas Quirúrgicas/efectos adversos , Dolor Crónico/etiología , Remoción de Dispositivos , Hernia Inguinal/cirugía , Humanos , Conducto Inguinal/inervación , Persona de Mediana Edad , Dimensión del Dolor , Dolor Postoperatorio/etiología , Nervios Periféricos/cirugíaRESUMEN
BACKGROUND AND AIM: Cardiovascular disease is the leading cause of death among patients with chronic kidney disease (CKD). Although there is emerging evidence that excess visceral fat is associated with a cluster of cardiometabolic abnormalities in these patients, the impact of visceral obesity evaluated by a gold-standard method on future outcomes has not been studied. We aimed to investigate whether visceral obesity assessed by computed tomography was able to predict cardiovascular events in CKD patients. METHODS AND RESULTS: We studied 113 nondialyzed CKD patients [60% men; 31% diabetics; age 55.3 ± 11.3 years; body mass index (BMI) 27.2 ± 5.3 kg/m(2); estimated glomerular filtration rate (GFR) 33.7 ± 13.6 ml/min/1.73 m(2)]. Visceral and subcutaneous abdominal fat were assessed by computed tomography at L4-L5. Visceral to subcutaneous fat ratio >0.55 (highest tertile cut-off) was defined as visceral obesity. Cardiovascular events including acute myocardial infarction, angina, arrhythmia, uncontrolled blood pressure, stroke and cardiac failure were recorded during 24 months. Cardiovascular events were 3-fold higher in patients with visceral obesity than in those without visceral obesity. The Kaplan-Meier analysis indicated that patients with visceral obesity had shorter cardiovascular event-free time than those without visceral obesity (P = 0.021). In the univariate Cox analysis, visceral obesity was associated with higher risk of cardiovascular events (hazard ratio = 3.4; 95% confidence interval = 1.1-10.5; P = 0.03). The prognostic power of visceral obesity for cardiovascular events remained significant after adjustments for sex, age, diabetes, previous cardiovascular disease, smoking, sedentary lifestyle, BMI, GFR, hypertension, dyslipidemia and inflammation. CONCLUSION: Visceral obesity assessed by computed tomography was a predictor of cardiovascular events in CKD patients.
Asunto(s)
Enfermedades Cardiovasculares/diagnóstico , Obesidad Abdominal/diagnóstico , Insuficiencia Renal Crónica/fisiopatología , Adulto , Índice de Masa Corporal , Enfermedades Cardiovasculares/etiología , Femenino , Tasa de Filtración Glomerular , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Obesidad Abdominal/complicaciones , Pronóstico , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Insuficiencia Renal Crónica/complicaciones , Factores de Riesgo , Grasa Subcutánea Abdominal/fisiopatología , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Cardiovascular disease (CVD) mortality is extremely high among kidney transplant recipients (KTRs), particularly in the first months after transplantation. Few data are available comparing the cardiovascular profile between KTRs from living versus deceased donors. OBJECTIVES AND METHODS: The aim of the present study was to evaluate the prevalence of CVD in the first 2 months following transplantation, among 120 KTRs of living versus deceased donor organs. RESULTS: Left ventricular hypertrophy was observed in 65% of patients, coronary artery calcification in 30%, and cardiac arrhythmias in 46%. CVD was more prevalent among KTRs from deceased versus living donors: ventricular hypertrophy 87% versus 59% (P = .008); coronary artery calcification 42% versus 24% (P = .04); and cardiac arrhythmias 59% versus 39% (P = .06). Multiple logistic regression analysis adjusted for age and dialysis vintage, showed graft donor to not be associated with the prevalence of any CVD (ß coefficient 0.912, 95% confidence interval 0.276-3.012, P = .88). CONCLUSION: In conclusion, the present study demonstrated an elevated prevalence of CVD among KTRs. Patient characteristics, mainly longer length on dialysis seemed to contribute to a greater prevalence of cardiovascular complications among KTRs from deceased compared with living donors on univariate but not multivariate analysis.
Asunto(s)
Enfermedades Cardiovasculares/epidemiología , Trasplante de Riñón , Donadores Vivos , Adulto , Arritmias Cardíacas/epidemiología , Brasil/epidemiología , Enfermedades Cardiovasculares/diagnóstico , Distribución de Chi-Cuadrado , Enfermedad de la Arteria Coronaria/epidemiología , Estudios Transversales , Femenino , Humanos , Hipertrofia Ventricular Izquierda/epidemiología , Trasplante de Riñón/efectos adversos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Prevalencia , Diálisis Renal , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Calcificación Vascular/epidemiologíaRESUMEN
BACKGROUND: Left ventricular hypertrophy (LVH) is a major cardiovascular complication in chronic kidney disease (CKD) patients. For a successful management of LVH, the comprehensive understanding of the classical and the new emerging factors associated with LVH is of paramount importance. The aim of the present study was to evaluate the clinical correlates of bone mineral metabolism with the occurrence of LVH in nondialyzed CKD patients. METHODS: This cross-sectional study included 96 patients with stages 2-4 CKD. Demographic characteristics, clinical profiles, laboratory tests and transthoracic echocardiogram were performed. RESULTS: LVH was observed in 36% of the patients. Patients with LVH were older, had a higher prevalence of hypertension, and higher levels of intact parathormone, fibroblast growth factor 23 and C-reactive protein. Serum phosphorus, alkaline phosphatase and vitamin D were not associated with the presence of LVH. In the multiple logistic regression analyses only FGF23 remained as a variable independently associated with LVH. CONCLUSION: We confirmed the high prevalence of LVH in nondialyzed CKD patients and showed that FGF23, an early marker of phosphorus load, was an important factor associated with LVH in these patients. Monitoring of FGF23 could be important for the management of LVH in this population.
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Factores de Crecimiento de Fibroblastos/sangre , Hipertrofia Ventricular Izquierda/etiología , Insuficiencia Renal Crónica/complicaciones , Adulto , Estudios Transversales , Femenino , Factor-23 de Crecimiento de Fibroblastos , Humanos , Hipertrofia Ventricular Izquierda/diagnóstico por imagen , Hipertrofia Ventricular Izquierda/epidemiología , Masculino , Persona de Mediana Edad , Fósforo/sangre , Prevalencia , UltrasonografíaRESUMEN
The aim of this study was to investigate whether slow graft function (SGF) after transplantation of deceased-donor kidneys affected the prevalence of anemia or the glomerular filtration rate (GFR). We retrospectively evaluated the records of 534 kidney transplant patients who were classified based on their initial renal function, namely, immediate graft function (IGF), slow graft function (SGF), or delayed graft function (DGF). Among the 534 kidney transplant patients studied, the occurrences of each condition were IGF 104, SGF 133, and DGF 297. Six months after transplantation, a greater percentage of DGF patients were anemic compared with the others (P = .028). However, at 12 months after transplantation, SGF patients showed more anemia than the IGF group. DGF and SGF patients displayed similar GFR values at 18 and 24 months after transplantation. However, IGF patients displayed higher GFRs, even when subjects who experienced acute rejection episodes were censored (P = .004). The incidence of acute rejection episodes was similar among SGF and DGF patients. Patients displaying SGF after deceased-donor transplantation showed a greater tendency to be anemic than those displaying IGF. This study also suggested that SGF patients were at risk for acute rejection episodes and/or significantly reduced kidney function as measured by GFR.
Asunto(s)
Tasa de Filtración Glomerular , Trasplante de Riñón/fisiología , Anemia/epidemiología , Cadáver , Funcionamiento Retardado del Injerto/epidemiología , Estudios de Seguimiento , Supervivencia de Injerto , Humanos , Inmunosupresores/efectos adversos , Inmunosupresores/uso terapéutico , Pruebas de Función Renal , Trasplante de Riñón/efectos adversos , Trasplante de Riñón/inmunología , Complicaciones Posoperatorias/epidemiología , Diálisis Renal , Estudios Retrospectivos , Factores de Tiempo , Donantes de Tejidos , Insuficiencia del TratamientoRESUMEN
BACKGROUND: Soluble Fas levels (sFas) are increased in the serum of uremic patients and are associated with the presence of anemia and recombinant human EPO (rHuEPO) dosage in dialysis patients. It is possible that sFas levels are associated with an increased need for serum erythropoietin levels (Epo) in chronic kidney disease and dialysis patients in order to maintain hematocrit (Hct) levels. AIMS: To investigate the relationship between serum sFas levels, serum Epo levels and the ratio between Epo levels and Hct in uremic patients. METHODS: We studied 52 predialysis chronic kidney disease patients (CKD; 33 M, 57 +/- 12 years, hematocrit (Hct) = 37 +/- 7%), 29 peritoneal dialysis patients (PD; 12 M, 54 +/- 14 years, Hct = 36 +/- 7%), 29 hemodialysis patients (HD; 19 M, 47 +/- 14 years, Hct = 33 +/- 5%) and 29 healthy volunteers (control group 17 M, 50 +/- 16 years, Hct = 43 +/- 3%). We examined the relationship between Hct and serum levels of Epo, sFas, C-reactive protein, IL-6 and iron status. The ratio of serum Epo divided by Hct (Epo/Hct) was used as an indicator of Epo responsiveness. RESULTS: Compared to normal subjects, the CKD, PD and HD groups presented lower Hct levels and higher serum levels of sFas, Epo, Epo/Hct and IL-6. Serum levels of sFas correlated negatively with albumin (r = -0.24, p = 0.02), IL-6 (r = -0.18, p = 0.04) and Epo/Hct (r = -0.37, p < 0.001). In multivariate analysis, after adjusting for markers of iron store and inflammation, only sFas correlated with Epo/Hct. In the CKD group, there were negative correlations between serum levels of sFas and glomerular filtration rate (GFR) (r = -0.45, p < 0.001) and between Epo/Hct and GFR (r = -0.32; p = 0.02). There was a positive correlation between Epo/Hct and serum levels of sFas in the CKD group (r = 0.31, p = 0.03) and in the HD groups (r = 0.58, p = 0.001). CONCLUSION: Our findings show that serum sFas is associated with higher Epo/Hct ratio, suggesting that sFas may be a marker of Epo hyporesponsiveness in uremia. Further studies are needed to determine whether sFas is just a marker of Epo hyporesponsiveness or is also involved in its pathophysiology.
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Eritropoyetina/sangre , Proteína Ligando Fas/sangre , Inflamación/sangre , Fallo Renal Crónico/sangre , Adulto , Anciano , Análisis de Varianza , Anemia Ferropénica/sangre , Anemia Ferropénica/complicaciones , Proteína C-Reactiva/metabolismo , Distribución de Chi-Cuadrado , Femenino , Humanos , Interleucina-6/sangre , Hierro/sangre , Fallo Renal Crónico/complicaciones , Masculino , Persona de Mediana Edad , Selección de Paciente , Análisis de Regresión , Diálisis RenalRESUMEN
PURPOSE: The aim of this study is to evaluate the usefulness of sutureless incisional open hernia repair with mesh fixation only using a fibrin glue sealant. METHODS: From 2002 to 2007, 40 patients underwent surgical recurrent incisional hernia repair, consisting of a sutureless positioning of a retromuscolar-preperitoneal polypropylene stiff mesh, fixed only with 2 ml of human fibrin glue. RESULTS: The average hospitalization period was 3 days; postoperative complications occurred in seven patients: wound infection in four patients and hematoma in three patients. Seroma was not observed. Postoperative pain occurred in two patients, while chronic pain occurred in one patient; the remaining 37 patients were pain-free. CONCLUSIONS: The use of an open retromuscolar mesh is an easy, inexpensive and relatively safe method to repair large incisional hernias. In our study the use of fibrin glue sealant demonstrated a low incidence of postoperative pain and short hospitalization.
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Adhesivo de Tejido de Fibrina/uso terapéutico , Hernia Abdominal/cirugía , Mallas Quirúrgicas , Procedimientos Quirúrgicos Operativos/métodos , Adulto , Anciano , Materiales Biocompatibles , Femenino , Estudios de Seguimiento , Hematoma/etiología , Hernia Abdominal/etiología , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Dolor Postoperatorio , Calidad de Vida , Recurrencia , Mallas Quirúrgicas/efectos adversos , Procedimientos Quirúrgicos Operativos/efectos adversos , Infección de la Herida Quirúrgica/etiologíaRESUMEN
Delayed graft function (DGF) is defined as the necessity for dialysis during the first week after transplantation. This study sought to describe patterns of dialysis prescription and evaluate the impact of dialysis dose in acute rejection. Among 82 patients who received a deceased donor kidney transplant, clinical and laboratory data were evaluated at the moment of dialysis indication. Prescribed and delivered dialysis doses (Kt/V and urea reduction ratio) were analyzed during the first dialysis and the first week (Kt/V) after transplantation. We examined the association between Kt/V and acute rejection. Prescribed Kt/V at the first dialysis session was adequate (2.24 +/- 0.51). However, delivered Kt/V was inadequate (0.75 +/- 0.38). Prescribed and delivered Kt/V during the first week after transplantation were suboptimal, namely, 2.45 +/- 1.52 and 1.56 +/- 0.99, respectively. Dialysis dose had no impact on the occurrence of an acute rejection episode. Among DGF patient, dialysis was prescribed late and a low dose was achieved.
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Funcionamiento Retardado del Injerto/terapia , Rechazo de Injerto/prevención & control , Trasplante de Riñón , Diálisis Renal , Adulto , Anciano , Femenino , Fluidoterapia , Humanos , Masculino , Persona de Mediana Edad , Selección de Paciente , Cuidados Posoperatorios , Receptores de Trasplantes , UreaRESUMEN
PURPOSE: Increased serum concentrations of soluble Fas (sFas) have been reported in patients with chronic kidney disease (CKD). However, little is known about the renal clearance of sFas, whether sFas is reabsorbed in the renal tubules, or the behavior of sFas synthesis in CKD. MATERIALS AND METHODS: We studied 69 patients with CKD (60+/-15 years old, creatinine clearance 37+19 ml/min/1.73 m2) and 14 healthy subjects (61+/-17 years, creatinine clearance 79+/-24 ml/min/1.73 m2). ELISA was used to measure the levels of sFas (pg/mL) and retinol binding protein (RBP - mg/L). RT-PCR was used to quantify sFasmRNA of leukocytes. RESULTS: Serum sFas levels were significantly higher in patients with CKD (2781+/-1214 vs. 2196+/-773, p=0.02). The concentrations of sFas in 24-hour urine samples (23+/-27 vs. 40+/-17, p=0.006) and sFas Clearance (0.019+/-0.022 vs. 0.036+/-0.020, p=0.01) were significantly lower in patients with CKD. sFas clearance correlated with creatinine clearance (r=0.25, p=0.02). Urine concentrations of RBP correlated with sFas concentrations in the urine (r=0.80, p<0.001). sFasmRNA were higher in patients with CKD (3.9+/-1.8 vs. 2.5+/-0.9, p<0.001). CONCLUSIONS: In CKD patients, the decrease in renal function is followed by a decrease in sFas clearance and an increase in serum sFas. In patients with proximal tubule dysfunction (high urinary RBP concentrations), urinary sFas is also increased, suggesting that sFas is reabsorbed by the proximal tubule. It is possible that an increase in sFas synthesis also contributes to the increase of serum sFas concentrations in uremia.
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Fallo Renal Crónico/metabolismo , Riñón/metabolismo , Receptor fas/metabolismo , Anciano , Estudios de Casos y Controles , Femenino , Humanos , Fallo Renal Crónico/sangre , Pruebas de Función Renal , Masculino , Persona de Mediana Edad , Proteínas de Unión al Retinol/metabolismo , Proteínas de Unión al Retinol/orina , Receptor fas/sangreRESUMEN
The guidelines proposed by the Kidney Disease Outcomes Quality Initiative (K/DOQI) suggested that intact parathyroid hormone (iPTH) should be maintained in a target range between 150 and 300 pg ml(-1) for patients with stage 5 chronic kidney disease. Our study sought to verify the effectiveness of that range in preventing bone remodeling problems in hemodialysis patients. We measured serum ionized calcium and phosphorus while iPTH was measured by a second-generation assay. Transiliac bone biopsies were performed at the onset of the study and after completing 1 year follow-up. The PTH levels decreased within the target range in about one-fourth of the patients at baseline and at the end of the study. The bone biopsies of two-thirds of the patients were classified as showing low turnover and a one-fourth showed high turnover, the remainder having normal turnover. In the group achieving the target levels of iPTH 88% had low turnover. Intact PTH levels less than 150 pg ml(-1) for identifying low turnover and greater than 300 pg ml(-1) for high turnover presented a positive predictive value of 83 and 62%, respectively. Our study suggests that the iPTH target recommended by the K/DOQI guidelines was associated with a high incidence of low-turnover bone disease, suggesting that other biochemical markers may be required to accurately measure bone-remodeling status in hemodialysis patients.
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Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/diagnóstico , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/prevención & control , Hormona Paratiroidea/sangre , Diálisis Renal/efectos adversos , Acetatos/uso terapéutico , Adulto , Biopsia , Remodelación Ósea , Brasil , Compuestos de Calcio/uso terapéutico , Quelantes/uso terapéutico , Enfermedad Crónica , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/patología , Femenino , Humanos , Enfermedades Renales/sangre , Enfermedades Renales/tratamiento farmacológico , Enfermedades Renales/patología , Masculino , Persona de Mediana Edad , Hormona Paratiroidea/normas , Poliaminas/uso terapéutico , Guías de Práctica Clínica como Asunto , Estudios Prospectivos , Valores de Referencia , SevelamerRESUMEN
AIM OF THE STUDY: The purpose of this study is to evaluate the sensitivity and specificity of free circulating DNA (CFDNA) as a potential tumour marker in patients suffering from colorectal cancer (CRC). MATERIALS AND METHODS: The quantification of plasma DNA was determined through the use of real-time quantitative polymerase chain reaction (PCR) amplification of the RNAse P gene. We studied patients undergoing surgery for primary CRC, at different stages of disease and a cohort of comparable healthy donors. Data were statistically analysed using Student's t-test. RESULTS: The mean DNA index of the tumour samples was 4771 ng/ml, about 50 times higher in comparison with healthy donors (mean value 0.85 ng/ml). In contrast the carcinoembryonic antigen (CEA) value of these patients was altered in only 47% of cases. CONCLUSION: This study shows that circulating free DNA levels in plasma of patients with CRC are significantly higher compared to healthy subjects, and suggest a new, non-invasive, approach for colon cancer detection and to identify high risk individuals for CRC screening.
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Neoplasias Colorrectales/sangre , ADN de Neoplasias/sangre , Anciano , Biomarcadores de Tumor/sangre , Estudios de Casos y Controles , Neoplasias Colorrectales/cirugía , Femenino , Humanos , Masculino , Reacción en Cadena de la PolimerasaRESUMEN
BACKGROUND: Chronic kidney disease (CKD) patients are at a high risk of dying from a cardiovascular event, mainly due to coronary calcification. Among the various uremic and dialysis-specific risk factors for coronary calcification are mineral metabolism disorders. The role that secondary hyperparathyroidism (SHPT) consequent to the altered calcium and phosphate metabolism plays in the pathogenesis of coronary calcification remains unclear. The aim of this study was to evaluate the prevalence of coronary artery calcification in dialysis patients with severe SHPT submitted to multislice coronary tomography (MSCT) and to identify risk factors for coronary calcification. METHODS: This study involved 23 adult dialysis patients (age >18 years) with severe SHPT who were candidates for parathyroidectomy (PTX). All were submitted to MSCT and bone densitometry during the month preceding PTX. Fasting blood samples were collected immediately before surgery. Markers of mineral metabolism, including ionized calcium, phosphorus, alkaline phosphatase, intact-parathyroid hormone (iPTH), osteoprotegerin (OPG) and soluble receptor activator of nuclear factor-kappaB ligand, were analyzed. Dyslipidemia was assessed by determination of LDL, HDL and VLDL-cholesterol and triglyceride levels. Agatston units (AU) were used to calculate calcium scores. RESULTS: No coronary calcification was found in 30% of the patients. Moderate (calcium score > 100 AU) and severe (calcium score >400 AU) calcification was observed in 12 and 36% of the patients, respectively. In the univariate analysis, calcium volume correlated positively with VLDL-cholesterol (r = 0.44; p = 0.03) and, albeit less than significantly, with age (r = 0.35; p = 0.09), triglycerides (r = 0.39; p = 0.05) and Framingham risk index (r = 0.37; p = 0.07). We also found that OPG correlated negatively with bone mineral density at the L2-L4 lumbar vertebrae (r = -0.54; p = 0.007) and femoral neck (r = -0.43; p = 0.04). CONCLUSIONS: Although high levels of PTH should be considered a risk factor for cardiovascular death, the real role of severe SHPT on coronary calcification is to be clarified.
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Calcinosis/fisiopatología , Enfermedad de la Arteria Coronaria/fisiopatología , Hiperparatiroidismo Secundario/fisiopatología , Insuficiencia Renal Crónica/fisiopatología , Adulto , Densidad Ósea , Calcinosis/diagnóstico , Calcinosis/epidemiología , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Diálisis Renal , Factores de Riesgo , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: Chronic kidney disease is associated with several metabolic disturbances that can affect energy metabolism. As resting energy expenditure (REE) is scarcely investigated in patients on hemodialysis (HD) therapy, we aimed to evaluate the REE and its determinants in HD patients. DESIGN: Cross-sectional study. SETTING: Dialysis Unit of the Nephrology Division, Federal University of São Paulo, Brazil. SUBJECTS: The study included 55 patients (28 male, 41.4+/-12.6 years old) undergoing HD therapy thrice weekly for at least 2 months, and 55 healthy individuals pair matched for age and gender. Subjects underwent fasting blood tests, as well as nutritional assessment, and the REE was assessed by indirect calorimetry. RESULTS: REE of HD patients was similar to that of pair-matched controls (1379+/-272 and 1440+/-259 kcal/day, respectively), even when adjusted for fat-free mass (P=0.24). REE of HD patients correlated positively with fat-free mass (r=0.74; P<0.001) and body mass index (r=0.37; P<0.01), and negatively with dialysis adequacy (r=-0.46; P<0.001). No significant univariate correlation was found between REE and age, dialysis vintage, serum creatinine, urea, albumin, bicarbonate, parathyroid hormone (PTH) or high-sensitivity C-reactive protein (CRP). In the multiple linear regression analysis, using REE as dependent variable, the final model showed that besides the well-recognized determinants of REE such as fat-free mass and age, PTH and CRP were the independent determinants of REE in HD patients (R (2)=0.64). CONCLUSIONS: In this study, the REE of HD patients was similar to that of healthy individuals, even with the positive effect of secondary hyperparathyroidism and inflammation on REE of these patients.
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Metabolismo Basal/fisiología , Composición Corporal/fisiología , Fallo Renal Crónico/metabolismo , Fallo Renal Crónico/terapia , Diálisis Renal , Adulto , Factores de Edad , Anciano , Brasil , Proteína C-Reactiva/metabolismo , Calorimetría Indirecta , Estudios de Casos y Controles , Estudios Transversales , Metabolismo Energético/fisiología , Femenino , Humanos , Hiperparatiroidismo Secundario/metabolismo , Hiperparatiroidismo Secundario/fisiopatología , Fallo Renal Crónico/sangre , Masculino , Persona de Mediana Edad , Músculo Esquelético/metabolismo , Evaluación Nutricional , Hormona Paratiroidea/sangreRESUMEN
Osteoporosis in hemodialysis patients is associated with high morbidity and mortality and, although extensively studied by noninvasive methods, has never been assessed through bone biopsy. The aim of this study was to use histomorphometry to evaluate osteoporosis and identify factors related to its development in hemodialysis patients. We conducted a cross-sectional study involving 98 patients (35 women and 63 men; mean age: 48.4 +/- 13 years) on hemodialysis for 36.9 +/- 24.7 months. Patients were submitted to transiliac bone biopsy with double tetracycline labeling. The bone metabolism factors ionized calcium, phosphorus, bone alkaline phosphatase, deoxypyridinoline, intact parathyroid hormone, and 25(OH) vitamin D were evaluated, as were the bone remodeling cytokines osteoprotegerin (OPG), soluble receptor-activator of NF-kappabeta ligand (sRANKL) and tumor necrosis factor-alpha (TNF)alpha. Osteoporosis was defined as trabecular bone volume (BV/TV) greater than 1 s.d. below normal (men <17.4%; women <14.7%). Forty-five patients (46%) presented osteoporosis, which was correlated with white race. We found BV/TV to correlate with age, OPG/sRANKL ratio, TNFalpha levels, and length of amenorrhea. In multiple regression analysis adjusted for sex and age, length of amenorrhea, white race, and OPG/sRANKL ratio were independent determinants of BV/TV. Histomorphometric analysis demonstrated that osteoporotic patients presented normal eroded surface and low bone formation rate (BFR/BS). Osteoporosis is prevalent in hemodialysis patients. Low BFR/BS could be involved in its development, even when bone resorption is normal. Cytokines may also play a role as may traditional risk factors such as advanced age, hypogonadism, and white race.
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Enfermedades Óseas Metabólicas/patología , Remodelación Ósea , Huesos/patología , Osteoporosis/metabolismo , Diálisis Renal/efectos adversos , Adulto , Anciano , Fosfatasa Alcalina/sangre , Aminoácidos/sangre , Biomarcadores/sangre , Biopsia , Calcio/sangre , Proteínas Portadoras/sangre , Estudios de Casos y Controles , Estudios Transversales , Femenino , Glicoproteínas/sangre , Humanos , Masculino , Glicoproteínas de Membrana/sangre , Persona de Mediana Edad , Osteoporosis/sangre , Osteoporosis/epidemiología , Osteoporosis/fisiopatología , Osteoprotegerina , Hormona Paratiroidea/sangre , Fósforo/sangre , Prevalencia , Ligando RANK , Receptor Activador del Factor Nuclear kappa-B , Receptores Citoplasmáticos y Nucleares/sangre , Receptores del Factor de Necrosis Tumoral/sangre , Vitamina D/análogos & derivados , Vitamina D/sangre , Población Blanca/estadística & datos numéricosRESUMEN
Some studies have suggested that intravenous iron therapy may be associated with an increased risk of infection. We analyzed the incidence of bacterial infection in 111 hemodialysis patients. Group 1 (n = 39, transferrin saturation <20%) received 10 doses of 100 mg of intravenous iron saccharate, 3 doses per week (28 treatment days); Group 2 (n = 13, transferrin saturation <20%) received 20 doses, 3 doses per week (70 treatment days); and Group 3 (n = 59, transferrin saturation 20-50%) received 10 doses, 1 dose per week (70 treatment days). The follow-up was 150 days for all groups, and all infectious episodes were recorded. Pulmonary infection was the most frequent event observed in all of the groups. In an incidence-density analysis, Group 2, which received a total of 20 doses, presented a significantly higher incidence of infection than Group 3, which received only 10 doses over the same period (0.13 versus 0.06 infections per patient per month, p = 0.04). No difference was observed between Groups 1 and 2 suggesting that the risk of infection during iron therapy is dose dependent rather than time length dependent.
Asunto(s)
Infecciones Bacterianas/etiología , Compuestos Férricos/administración & dosificación , Diálisis Renal , Sacarosa/administración & dosificación , Adulto , Femenino , Sacarato de Óxido Férrico , Ácido Glucárico , Humanos , Masculino , Persona de Mediana EdadRESUMEN
The repercussions of secondary hyperparathyroidism on the nutritional status of chronic renal failure patients have not been well established. Therefore, the aim of this study was to compare the nutritional indices of hemodialysis patients with and without secondary hyperparathyroidism. Sixteen hemodialysis patients with serum parathyroid hormone (PTH) levels higher than 420 pg/ml (hyperparathyroidism group) were matched for gender, age and length of dialysis treatment to 16 patients with serum PTH between 64 and 290 pg/ml (control group). The following parameters were assessed: anthropometric indices (body mass index, skinfold thickness, midarm muscle circumference and body fat), 4-day food diaries, protein catabolic rate, biochemical indices (blood urea nitrogen, serum creatinine, albumin, ionized calcium, inorganic phosphorus, serum alkaline phosphatase, PTH, pH and HCO3) and dialysis efficiency. We did not observe differences in the anthropometric indices between the two groups. Only calcium intake was significantly different between groups (307.9 mg/day for the hyperparathyroidism group vs 475.8 mg/day for the control group). Protein catabolic rate tended to be higher in the hyperparathyroidism group compared to the control group (1.3 vs 0.9 g kg-1 day-1; P = 0.08). Except for blood urea nitrogen (86.4 vs 75.7 mg/dl), alkaline phosphatase (175 vs 65 U/l) and PTH (898 vs 155 pg/ml), no other differences were found between groups in the biochemical indices studied. PTH was directly correlated with protein catabolic rate (r = 0.61; P<0.05) and length of dialysis (r = 0.53; P<0.05) only in the hyperparathyroidism group. Considering the indices used, we could not demonstrate the deleterious effect of high PTH levels on the nutritional status of hemodialysis patients. Indirect evidence, however, suggests an action of PTH on protein metabolism
Asunto(s)
Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Hiperparatiroidismo Secundario/sangre , Fallo Renal Crónico/sangre , Estado Nutricional , Diálisis Renal , Anciano de 80 o más Años , Antropometría , Estudios de Casos y Controles , Fallo Renal Crónico/terapia , Hormona Paratiroidea/sangre , Estadísticas no ParamétricasRESUMEN
The repercussions of secondary hyperparathyroidism on the nutritional status of chronic renal failure patients have not been well established. Therefore, the aim of this study was to compare the nutritional indices of hemodialysis patients with and without secondary hyperparathyroidism. Sixteen hemodialysis patients with serum parathyroid hormone (PTH) levels higher than 420 pg/ml (hyperparathyroidism group) were matched for gender, age and length of dialysis treatment to 16 patients with serum PTH between 64 and 290 pg/ml (control group). The following parameters were assessed: anthropometric indices (body mass index, skinfold thickness, midarm muscle circumference and body fat), 4-day food diaries, protein catabolic rate, biochemical indices (blood urea nitrogen, serum creatinine, albumin, ionized calcium, inorganic phosphorus, serum alkaline phosphatase, PTH, pH and HCO(3)) and dialysis efficiency. We did not observe differences in the anthropometric indices between the two groups. Only calcium intake was significantly different between groups (307.9 mg/day for the hyperparathyroidism group vs 475.8 mg/day for the control group). Protein catabolic rate tended to be higher in the hyperparathyroidism group compared to the control group (1.3 vs 0.9 g kg(-1) day(-1); P = 0.08). Except for blood urea nitrogen (86.4 vs 75.7 mg/dl), alkaline phosphatase (175 vs 65 U/l) and PTH (898 vs 155 pg/ml), no other differences were found between groups in the biochemical indices studied. PTH was directly correlated with protein catabolic rate (r = 0.61; P<0.05) and length of dialysis (r = 0.53; P<0.05) only in the hyperparathyroidism group. Considering the indices used, we could not demonstrate the deleterious effect of high PTH levels on the nutritional status of hemodialysis patients. Indirect evidence, however, suggests an action of PTH on protein metabolism.
Asunto(s)
Hiperparatiroidismo Secundario/sangre , Fallo Renal Crónico/sangre , Estado Nutricional , Adulto , Anciano , Anciano de 80 o más Años , Antropometría , Estudios de Casos y Controles , Femenino , Humanos , Hiperparatiroidismo Secundario/fisiopatología , Fallo Renal Crónico/terapia , Masculino , Hormona Paratiroidea/sangre , Estadísticas no ParamétricasRESUMEN
Central venous catheterization is a common technique to establish rapid and temporary access for hemodialysis. However, it is a known risk factor for Staphylococcus aureus infection and bacteremia. Mupirocin is a topical antibiotic with high in vitro anti-staphylococcal activity. A randomized prospective trial was conducted to assess the effectiveness of mupirocin ointment in the prevention of Staphylococcus aureus skin and catheter colonization, and episodes of bacteremia in 136 end-stage renal disease patients. Of these, 67 received skin disinfection at the venous catheter insertion site with povidone iodine (control group), and 69 received the same treatment followed by application of 2% mupirocin ointment at the cannula site after catheter placement and at the end of each dialysis session. Patients were followed until catheter removal and were monitored for the development of Staphylococcus aureus skin/catheter colonization and episodes of bacteremia. Median duration of catheter use was greater in the mupirocin than in the control group (37 versus 20 d, P < 0.01). Patients in the mupirocin group had a significantly lower rate of Staphylococcus aureus isolation from the pericatheter skin (1.76 per 1000 versus 14.27 per 1000 patient-days, P < 0.001) and from the catheter surface (3.17 per 1000 versus 14.27 per 1000 patient-days, P < 0.001). The proportion of patients with Staphylococcus aureus skin infection at the insertion site was lower in the mupirocin group (4.3% versus 23.9%, P = 0.001). Staphylococcus aureus-associated bacteremia was observed in 17 patients (two in the mupirocin group [0.71 episodes per 1000 patient-days] and 15 in the control group [8.92 per 1000 patient-days], P < 0.001). The hazard ratio of developing Staphylococcus aureus bacteremia was 7.2 (95% confidence interval, 1.6 to 31.6) times greater in patients not receiving mupirocin. Mupirocin applied to the insertion site significantly reduces the risk of Staphylococcus aureus skin and catheter colonization, exit-site infection, and Staphylococcus aureus bacteremia in hemodialysis patients.