Safety and Efficacy of Vadadustat for Anemia in Patients Undergoing Dialysis.

BACKGROUND: Vadadustat is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor, a class of compounds that stimulate endogenous erythropoietin production. METHODS: We conducted two randomized, open-label, noninferiority phase 3 trials to evaluate the safety and efficacy of vadadustat, as compared with darbepoetin alfa, in patients with anemia and incident or prevalent dialysis-dependent chronic kidney disease (DD-CKD). The primary safety end point, assessed in a time-to-event analysis, was the first occurrence of a major adverse cardiovascular event (MACE, a composite of death from any cause, a nonfatal myocardial infarction, or a nonfatal stroke), pooled across the trials (noninferiority margin, 1.25). A key secondary safety end point was the first occurrence of a MACE plus hospitalization for either heart failure or a thromboembolic event. The primary and key secondary efficacy end points were the mean change in hemoglobin from baseline to weeks 24 to 36 and from baseline to weeks 40 to 52, respectively, in each trial (noninferiority margin, -0.75 g per deciliter). RESULTS: A total of 3923 patients were randomly assigned in a 1:1 ratio to receive vadadustat or darbepoetin alfa: 369 in the incident DD-CKD trial and 3554 in the prevalent DD-CKD trial. In the pooled analysis, a first MACE occurred in 355 patients (18.2%) in the vadadustat group and in 377 patients (19.3%) in the darbepoetin alfa group (hazard ratio, 0.96; 95% confidence interval [CI], 0.83 to 1.11). The mean differences between the groups in the change in hemoglobin concentration were -0.31 g per deciliter (95% CI, -0.53 to -0.10) at weeks 24 to 36 and -0.07 g per deciliter (95% CI, -0.34 to 0.19) at weeks 40 to 52 in the incident DD-CKD trial and -0.17 g per deciliter (95% CI, -0.23 to -0.10) and -0.18 g per deciliter (95% CI, -0.25 to -0.12), respectively, in the prevalent DD-CKD trial. The incidence of serious adverse events in the vadadustat group was 49.7% in the incident DD-CKD trial and 55.0% in the prevalent DD-CKD trial, and the incidences in the darbepoetin alfa group were 56.5% and 58.3%, respectively. CONCLUSIONS: Among patients with anemia and CKD who were undergoing dialysis, vadadustat was noninferior to darbepoetin alfa with respect to cardiovascular safety and correction and maintenance of hemoglobin concentrations. (Funded by Akebia Therapeutics and Otsuka Pharmaceutical; INNO2VATE ClinicalTrials.gov numbers, NCT02865850 and NCT02892149.).

Elevated level of lysophosphatidic acid among patients with HNF1B mutations and its role in RCAD syndrome: a multiomic study.

INTRODUCTION: Patients with hepatocyte nuclear factor-1 beta (HNF1B) mutations present a variable phenotype with two main symptoms: maturity onset diabetes of the young (MODY) and polycystic kidney disease (PKD). OBJECTIVES: Identification of serum metabolites specific for HNF1Bmut and evaluation of their role in disease pathogenesis. METHODS: We recruited patients with HNF1Bmut (N = 10), HNF1Amut (N = 10), PKD: non-dialyzed and dialyzed (N = 8 and N = 13); and healthy controls (N = 12). Serum fingerprinting was performed by LC-QTOF-MS. Selected metabolite was validated by ELISA (enzyme-linked immunosorbent assay) measurements and then biologically connected with HNF1B by in silico analysis. HepG2 were stimulated with lysophosphatidic acid (LPA) and HNF1B gene was knocked down (kd) by small interfering RNA. Transcriptomic analysis with microarrays and western blot measurements were performed. RESULTS: Serum levels of six metabolites including: arachidonic acid, hydroxyeicosatetraenoic acid, linoleamide and three LPA (18:1, 18:2 and 20:4), had AUC (the area under the curve) > 0.9 (HNF1Bmut vs comparative groups). The increased level of LPA was confirmed by ELISA measurements. In HepG2HNF1Bkd cells LPA stimulation lead to downregulation of many pathways associated with cell cycle, lipid metabolism, and upregulation of steroid hormone metabolism and Wnt signaling. Also, increased intracellular protein level of autotaxin was detected in the cells. GSK-3alpha/beta protein level and its phosphorylated ratio were differentially affected by LPA stimulation in HNF1Bkd and control cells. CONCLUSIONS: LPA is elevated in sera of patients with HNF1Bmut. LPA contributes to the pathogenesis of HNF1B-MODY by affecting Wnt/GSK-3 signaling.

A potential link between AQP3 and SLC14A1 gene expression level and clinical parameters of maintenance hemodialysis patients.

BACKGROUND: The transport of water and urea through the erythrocyte membrane is facilitated by aquaporins such as aquaglyceroporin (AQP3), and type B urea transporters (UT-B). As they may play an important role in osmotic balance of maintenance hemodialysis (HD) patients, the aim of the present study was to determine whether any relationship exists between the expression of their genes and the biochemical / clinical parameters in HD patients. METHODS: AQP3 and UT-B (SLC14A1) gene expression was evaluated using RT-qPCR analysis in 76 HD patients and 35 participants with no kidney failure. RESULTS: The HD group demonstrated significantly higher median expression of AQP3 and UT-B (Z = 2.16; P = 0.03 and Z = 8.82; p < 0.0001, respectively) than controls. AQP3 negatively correlated with pre-dialysis urea serum concentration (R = -0.22; P = 0.049) and sodium gradient (R = -0.31; P = 0.04); however, no significant UT-B correlations were observed. Regarding the cause of end-stage kidney disease, AQP3 expression positively correlated with erythropoietin dosages in the chronic glomerulonephritis (GN) subgroup (R = 0.6; P = 0.003), but negatively in the diabetic nephropathy subgroup (R = -0.59; P = 0.004). UT-B positively correlated with inter-dialytic weight gain% in the GN subgroup (R = 0.47; P = 0.03). CONCLUSION: Maintenance hemodialysis seems significantly modify AQP3 and UT-B expression but their link to clinical and biochemical parameters needs further large-scale evaluation.

The Maintenance Immunosuppression Scheme Influences Early C4d Urinary Excretion in Kidney Graft Recipients but Does Not Affect the Long-term Graft Survival.

C4d urinary excretion varies according to the risk of graft rejection or progression of chronic allograft nephropathy. The most common maintenance immunosuppression (IS) schemes include cyclosporine (CSA) or tacrolimus (TAC) with azathiopryne (AZA) or mycophenolate mophetil (MMF). The chosen IS may influence kidney transplant outcomes and possibly modify urinary C4d. The aim of the study was to determine whether early C4d urinary excretion varies in patients after kidney allograft transplantation (KTx) regarding administered IS and if these factors may help to predict long-term KTx outcomes. The study involved 185 patients who underwent KTx. The urinary specimens were assessed by enzyme-linked immunosorbent assay test for C4d excretion. To increase the objectivity, C4d excretion was divided by urinary creatinine excretion (ng/mgCr). The study population was grouped according to the IS scheme, that is, CSA + AZA, CSA + MMF, and TAC + MMF. At baseline, the greatest C4d urinary excretion was noticed in patients treated with CSA + AZA, 199.5 ± 175.9 ng/mL (5.3 ± 7.1 ng/mgCr) and the lowest in those in whom tacrolimus and mycophenolate mophetil was administered, 166.6 ± 186.3 ng/mL (3.9 ± 6.2 ng/mgCr). In the CSA + MMF group, C4d excretion was 195.6 ± 200.3 ng/mL (5.0 ± 6.6 ng/mgCr). Statistically significant differences were seen only between the CSA + AZA and TAC + MMF groups, analysis of variance P < 0.05 (P < 0.01 for C4d/urinary creatinine ratio). No statistically significant differences were found in graft survival rates between different immunosuppressive regimens. Although early C4d measurements vary in patients after kidney allograft transplantation regarding administered IS, this IS dependant variation does not seem to affect the long-term graft survival.

A Taurolidine-Citrate-Heparin Lock Solution Effectively Eradicates Pathogens From the Catheter Biofilm in Hemodialysis Patients.

Catheter-related bacteremia (CRB) is a typical complication of hemodialysis catheter use. Catheter lumen colonization by pathogens is regarded as a direct cause of CRB. Once settled, the catheter biofilm increases the risk of developing infection, thus necessitating insertion replacement and antibiotic treatment. The study assessed the self-sufficient efficacy of taurolidine-citrate-heparin lock solution in eradicating catheter biofilm bacteria and keeping it sterile in patients on hemodialysis. Twenty-nine chronic patients on hemodialysis with tunneled and nontunneled catheters locked with a heparin filling (the mean time of heparin lock use -30.1 ± 2.0 days) and subsequently converted to a taurolidine-citrate-heparin filling were included. Peripheral vein and catheter lumen blood cultures were obtained before the filling change and after taurolidine-citrate-heparin lock use (mean time 33.8 ± 7.6 days). Twenty-four participants with tunneled and nontunneled catheters locked with taurolidine-citrate-heparin filling served as the control group. During the heparin-locking period, CRB was diagnosed in 3 cases (only nontunneled catheters). The catheter blood cultures findings were positive in 23 patients (10 temporary and 13 permanent catheters), whereas both the catheter and peripheral vein blood cultures were sterile in 3 of 29 subjects (only permanent catheters). Irrespective of catheter type (tunneled or nontunneled), repeated culture revealed no pathogens in any of the 23 patients with initial positive catheter blood culture, after the use of taurolidine-citrate-heparin filling. No positive blood culture was noted in the control group. The taurolidine-citrate-heparin lock solution effectively eradicated pathogens from nontunneled and tunneled catheter biofilms and helped to maintain catheter lumen sterility.

Macrophage migration inhibitory factor urinary excretion revisited ­ MIF a potent predictor of the immunosuppressive treatment outcomes in patients with proliferative primary glomerulonephritis.

BACKGROUND: Macrophage migration inhibitory factor (MIF) is a cytokine that shares many activities with other pro-inflammatory cytokines in primary glomerulonephritis (GN). This study assesses the influence of immunosuppressive treatment on serum and urine MIF in patients with proliferative (PGN) and non-proliferative (NPGN) glomerulonephritis, and evaluates the potential of MIF in predicting outcomes. METHODS: Eighty-four patients (45 males and 39 females) with primary GN were included. Urinary excretion of MIF (ng/mg of urinary creatinine) was measured both pre- and post-treatment with combined steroids and cyclophosphamide. After a 12-month follow-up, the patients were retrospectively divided into four subgroups: responders of proliferative GN (R-PGN), non-responders of proliferative GN (NR-PGN), responders of non-proliferative GN (R-NPGN) and non-responders of non-proliferative GN (NR-NPGN). RESULTS: The median pre-treatment urinary MIF values were higher in PGN than in NPGN (3.6 versus 2.2; ANOVA P = 0.039). The highest pre-treatment urinary excretion of MIF was observed in NR-PGN (median 6.1), which was significantly higher than other subgroups (ANOVA P < 0.05). The treatment significantly reduced MIF urinary excretion only in R-PGN (P < 0.01). In NR-PGN, pre- (5.9 ± 2.9 pg/mgCr) and post-treatment mean MIF excretion (4.9 ± 2.3 pg/mgCr) exceeded the calculated cut off value (3.3 pg/mgCr). CONCLUSION: MIF urinary excretion appears to be a prognostic marker of therapy outcomes only in proliferative glomerulonephritis, in which lower urinary MIF may be linked with good prognosis, whereas a higher MIF urinary excretion value was a marker of unfavorable therapy outcomes. In Non-Responders, urinary MIF measurements may help to reconsider the choice of the immunosuppressive regimen at early stages of the treatment and act as an impulse to search for new therapeutic strategies.

[The early C4d urinary excretion and long-term kidney graft survival in patients treated with tacrolimus and mycophenolate mophetil]. / Wczesne wydalanie z moczem C4d a odlegle przezycie przeszczepu nerki u chorych leczonych takrolimusem i mykofenolanem mofetylu.

UNLABELLED: The C4d urinary excretion seems to increase with the risk of graft rejection or progression of chronic allograft nephropathy although its impact on long-term kidney transplant (KTx) outcomes remains unclear. Presently the most common maintenance immunosuppression schemes (IS) includes corticosteroids and cyclosporine or tacrolimus (Tac) with mycophenolane mophetil (MMF), and Tac combined with MMF is regarded to be superior to other schemes. The aim of the study was to determine whether the initial (1-3 months post KTx) level of C4d urinary excretion may help to predict long-term kidney allograft transplantation outcomes in patients treated with Tac+MMF as maintenance IS. MATERIAL AND METHODS: The study involved 66 patients who had undergone kidney allograft transplantation. The urine specimens taken from the morning urine portion was assessed by ELISA test for C4d excretion. To increase the objectivity of the assessment all measurements were divided by urinary creatinine excretion (ng/mgCr). The study population was grouped according the calculated Roc curve (the cut off value of the urinary C4d excretion 13.1 ng/mgCr; AUC 0.93; 95% CI 0.74-0.95) into LC4d and HC4d, C4d below or above 13.1 ng/mgCr. RESULTS: The mean C4d urinary excretion was 166.6 +/- 186.3 ng/mL (3.9 +/- 6.2 ng/mgCr), in LC4d and HC4d 34.8 +/- 102.2 ng/mL (1.1 +/- 6.4 ng/mgCr) and 347.3 +/- 255.7ng/mL (19.2 +/- 5.9 ng/mgCr), respectively. In accord with the division of study population, the statistically significant differences were seen between LC4d and HC4d in urinary C4d excretion Z = 4.4; p = 0.019 (Z = 4.9, p = 0.011 for excretion calculated per urinary creatinine). Kaplan-Meier curve analysis demonstrated a higher graft survival rate in LC4d than in HC4d group (p = 0.048 by log-rank) in ten years follow-up. CONCLUSIONS: In patients treated with tacrolimus and mycophenolate mophetil as a maintenance immunosuppression, the lower C4d urinary excretion in the early post-transplant period seems to be a low significance prognostic marker of a better long-term kidney allograft transplantation outcome.

[The influence of maintenance immunosuppression scheme on D4d urinary excretion in kidney graft recipients]. / Wplyw wyboru podtrzymujacego schematu immunosupresji na wydalanie z moczem skladnika dopelniacza C4d u chorych po przeszczepie nerki.

INTRODUCTION: The C4d urinary excretion varies according to the risk of graft rejection or progression of chronic allograft nephropathy. The most common maintenance immunosuppression (IS) schemes includes cyclosporine (CSA) ortacrolimus (TAC with azathiopryne (AZA) or mycophenolane mophetil (MMF). The chosen IS may influence on the kidney transplant outcomes and possibly modify C4d urinary secretion. The aim of the study was to assess whether IS scheme may influence on C4d urinary excretion. MATERIAL AND METHODS: The study involved 185 patients who underwent kidney allograft transplantation (KTx).The urinary specimens taken from the morning urine portion was assessed by ELISA test for C4d excretion. To increase the objectivity of the assessment all measurements were divided by urinary creatinine excretion (ng/mg Ucr). The study population was grouped according the IS scheme, i.e., CSA+AZA, CSA+MMF and TAC+MMF. RESULTS: The highest C4d urinary excretion was noticed in patients treated with CSA+AZA--210 +/- 229 ng/ml (5.1 +/- 7.9 ng/mg Ucr) and the lowest in those in whom tacrolimus and mycophenolane mophetil was administered -198?188 ng/ml (4.4 +/- 7.1 ng/mg Ucr). In CSA+MMF group C4d excretion was 207?256 ng/ml (4.7 +/- 7.7 ng/mg Ucr). The statistically significant differences were seen only between CSA+AZA and TAC+MMF groups--ANOVA p<0.05 (p<0.01 for excretion calculated per Ucr). CONCLUSIONS: C4d urinary excretion in kidney graft recipients depends on immunosuppression scheme and is the lowest in patients treated with tacrolimus and mycophenolane mophetil.

[The influence of pre-transplantation dialysis modality on late C4d urinary excretion in kidney graft recipients]. / Wplyw przedtransplantacyjnej metody dializoterapii na pózne wydalanie z moczem skladnika dopelniacza C4d u chorych po przeszczepie nerki.

INTRODUCTION: The C4d deposits as well as its urinary excretion are markers of the humoral acute kidney graft rejection. The pre-transplant dialysis modality influences on the post-transplant outcomes and it is possible that it may modify C4d urinary excretion. AIM: The aim of the study was the assessment of the pre-transplant dialysis modality on late C4d urinary excretion. MATERIAL AND METHODS: The study comprised 185 patients who underwent kidney allograft transplantation (KTx). The urinary specimens taken from the morning urine portion was assessed by ELISA test for C4d excretion. To increase the objectivity of the assessment all measurements were divided by urinary creatinine excretion. The study population was grouped according the pre-transplant dialysis modality i.e. hemo- and peritoneal dialysis RESULTS: In the study the C4d urinary excretion in patients treated with hemodialysis was higher than in peritoneal dialysis, irrespectively whether in direct measurements 221.1 ± 239.9 ng/ml vs 156.4 ± 188.7 ng/ml (p < 0.05) or when calculated per urinary creatinine 5.2 ± 7.1 ng/mgCr i 3.4 ± 7.9 ng/mgr (p < 0.05). CONCLUSIONS: Pre-transplant dialysis modality influences late C4d urinary excretion.

[The assessment of C4d urinary excretion in early and late post kidney transplant periods]. / Ocena wydalania z moczem skladnika dopelniacza C4d we wczesnym i póznym okresie po transplantacji nerki.

INTRODUCTION: Recent data describes the involvement of compliment elements in humoral kidney graft rejection. The C4d deposits in peritubular capilars are the marker of compliment activity and the element of humoral acute graft rejection. The aim of the study was the assessment of C4d urinary excretion in early and late post-kidney transplant periods. MATERIAL AND METHODS: The study comprised 185 patients who underwent kidney allograft transplantation (KTx). The urinary specimens taken from the morning urine portion was assessed by ELISA test for C4d excretion. To increase the objectivity of the assessment all measurements were divided by urinary creatinine excretion. The study population was grouped according the post-transplant time i.e. <1 and >1 year after KTx. RESULTS: In the study the C4d urinary excretion in patients <1 year and >1 year post kidney transplantation were 4.6 ± 7.5 and 5.3 ± 7.9 ng/mgCr, respectively. The mean C4d excretion was 4.8 ± 7.6 ng/mgCr. The values did not differ significantly. The direct assessment of C4d excretion (not divided per creatinuria) were also comparable in the study groups (207.2 ± 261.8 ng/ml and 212.9 ± 249.3 ng/ml, respectively). CONCLUSIONS: C4d urinary excretion did not depend on post-transplant time.

Predictive value of conjointly examined IL-1ra, TNF-R I, TNF-R II, and RANTES in patients with primary glomerulonephritis.

Interleukin-1 receptor antagonist (IL-1ra), tumor necrosis factor soluble receptors (sTNF-R) type I and II, and regulated upon activation, normal T-cell expressed and secreted (RANTES) play an important role in the modulation of primary glomerulonephritis (GN) course. The aim of the study was to assess whether pre-treatment measurements of IL-1ra, sTNF-R, and RANTES assessed conjointly may be useful as predicting factors in patients with GN. In 84 patients (45 males and 39 female) serum concentration (pg/mL) and urinary excretion (pg/mgCr) of cytokines were measured. After 12 months of therapy with steroids and cyclophosphamide the patients were divided into two subgroups: Responders (R) and Non-Responders (NR) according to the treatment results. The urinary IL-1ra, TNF-RI and RII were significantly higher in R than NR (1,732 vs 646 with P < 0.001, 13.1 vs 6.3 with P = 0.005, and 33.6 vs 14.4 with P = 0.012). The urinary RANTES excretion was increased in NR (79.6 vs 28.5; P < 0.001). The multivariable analysis showed that if conjointly assessed, only urinary IL-1ra, TNF-R I and R II, RANTES with 85% probability pointed the feature remission (R). In conclusion, the urinary excretion of IL-1ra, TNF-R I and R II, and RANTES examined conjointly are effective in predicting favorable response to immunosuppressive treatment in patients with GN.

S-Fas urinary excretion helps to predict the immunosuppressive treatment outcomes in patients with proliferative primary glomerulonephritis.

Deregulation of soluble apoptosis stimulating fragment (sFas) plays an important role in glomerulonephritis (GN). The study assed the influence of immunosuppressive treatment on serum and urine sFas in patients with proliferative (PGN) and non-proliferative (NPGN) GN, and evaluated the potential of sFas measurements in predicting outcomes. Eighty-four patients with GN (45 males and 39 females) were included. Serum concentration (ng/mL) and urinary excretion (ng/mg of urinary creatinine) of sFas were measured before and after the treatment. After 12 months of therapy with steroids and cyclophosphamide, patients were divided into two subgroups according to the treatment results: Responders (R) and Non-Responders (NR). The sFas urinary excretion was reduced after treatment in both PGN and NPGN (from 17.12 ± 15 to 5.3 ± 4.2, P = 0.008 and from 10.11 ± 6.1 to 3.4 ± 3.0, P = 0.039; respectively) whereas the sFas serum concentration remained unchanged. In PGN, pre-treatment urinary sFas concentration was significantly lower in the Responders than in Non-Responders (2.3 ± 3.1 vs 19.4 ± 14.1, P = 0.003), and was lower still than in both R (P = 0.044) and NR (P = 0.042) subgroups with NPGN. The immunosuppressive treatment reduced sFas urinary excretion in proliferative and non-proliferative GN and results suggest that the lower urinary sFas may be linked with favorable therapy outcomes in patients with PGN.

Does oral health contribute to post-transplant complications in kidney allograft recipients?

OBJECTIVE: The significant number of complications in kidney graft recipients can not be easily explained. The paper assesses whether poor oral health increases the risk of acute rejections and hospitalizations in kidney allograft recipients. MATERIALS AND METHODS: Ninety-one kidney transplant recipients were divided into three sub-groups according to post-transplant time (< 1, 1-5 and > 5 years). Dental examination evaluated oral hygiene index (OHI-S) and Community Periodontal Index of Treatment Needs (CPITN), which were correlated with the occurrence of post-transplant complications. RESULTS: Within the first year after transplantation the indicators of the increased risk of hospitalizations and acute rejection episodes was the OHI-S (hazard ratio 1.02 and 1.11, respectively), also CPITN score correlated with acute rejections (R = 0.82, p < 0.01). CONCLUSION: The neglect in oral health is associated with the increased risk of clinical complications within first year after kidney transplantation.

The Effects of Two Kinds of Dietary Interventions on Serum Metabolic Profiles in Haemodialysis Patients.

The goal of this study was to evaluate the effects of two kinds of 24-week dietary interventions in haemodialysis patients, a traditional nutritional intervention without a meal before dialysis (HG1) and implementation of a nutritional intervention with a meal served just before dialysis (HG2), in terms of analysing the differences in the serum metabolic profiles and finding biomarkers of dietary efficacy. These studies were performed in two homogenous groups of patients (n = 35 in both groups). Among the metabolites with the highest statistical significance between HG1 and HG2 after the end of the study, 21 substances were putatively annotated, which had potential significance in both of the most relevant metabolic pathways and those related to diet. After the 24 weeks of the dietary intervention, the main differences between the metabolomic profiles in the HG2 vs. HG1 groups were related to the higher signal intensities from amino acid metabolites: indole-3-carboxaldehyde, 5-(hydroxymethyl-2-furoyl)glycine, homocitrulline, 4-(glutamylamino)butanoate, tryptophol, gamma-glutamylthreonine, and isovalerylglycine. These metabolites are intermediates in the metabolic pathways of the necessary amino acids (Trp, Tyr, Phe, Leu, Ile, Val, Liz, and amino acids of the urea cycle) and are also diet-related intermediates (4-guanidinobutanoic acid, indole-3-carboxyaldehyde, homocitrulline, and isovalerylglycine).

[The influence of side effects related to cinacalcet therapy on compliance in hemodialysis patients suffering from secondary hyperparathyroidism]. / Wplyw wystepowania dzialan niepozadanych na przestrzeganie zalecen terapeutycznych przez chorych przewlekle hemodializowanych leczonych cynakalcetem z powodu wtórnej nadczynnosci przytarczyc.

INTRODUCTION: Secondary hyperparathyroidism (sHPT) in hemodialysis patients often requires an introduction of calcimimetic (cinacalcet) therapy. This medication effectively reduces parathormon (iPTH) serum concentration and modifies calcium phosphorus score, however its oral administration often implicates the occurrence of side effects which may worsen adherence to this medication. The aim of the study was to asses the influence of cinacalcet therapy side effects on patients adherence to the regiment prescription in hemodialysis patients suffering from secondary hyperparathyroidism MATERIAL AND METHODS: Fifty six participants (male 26 and 30 female) in age of 36-75 years, on maintenance hemodialysis 3 times a week, mean session time 4 hours and 25 minutes, treated with orally administered cinacalcet due to sHPT, were involved in the study. The initial dose 30 mg was modified once a visit (an increase or a decrease of 30 mg, if necessary) according to serum iPTH--cinacalcet maximal mean dose was 86 mg. During the treatment any presence of cinacalcet side effect and its intensity was noted. Patients'adherence to medication basing on medication intake were calculated and over 70% intake of cinacalcet doses was regarded as the good adherence. RESULTS: Twenty eight of 56 participants treated with cinacalcet were excluded mainly due to non-compliance. In the cohort, a total number of 70 cases of side effects were noted. In patients who resigned of the treatment the occurrence of cinacalcet adverse events (AE) was not higher than in participants continuing therapy (p > 0.05). Additionally in this group sever AE due to hypocalcaemia i.e. paresthesia, weakness, was rarely reported. In patients with good adherence side effects were presented with similar incidence in comparison to non-compliance patients. CONCLUSION: The incidence of cinacalcet adverse events was regarded as the factor which had an insignificant influence on patients'adherence to this medication. Therefore, it is essential to monitor patients'compliance to decrease non-adherence episodes.

Effects of the Malnutrition-Eat Additional Meal (MEAM) Diet on the Serum Levels of Albumin and C-Reactive Protein in Hemodialysis Patients.

The main objective of this project was to evaluate the efficiency of two kinds of nutritional intervention implemented in hemodialysis patients for 24 weeks (traditional nutritional intervention without a meal served before dialysis for group HG1, and nutritional intervention involving a meal served before dialysis for group HG2), and their impact on nutritional status and serum concentrations of C-reactive protein (CRP). Nutritional status and serum biochemical parameters were analyzed in the control group (CG, n = 70) and in two homogeneous groups of patients, HG1 (n = 35) and HG2 (n = 35). There was an interesting trend in both groups of patients connected with increased intake, mainly of energy and protein. In HG1, the greatest increase in energy intake was observed on Sundays, and in HG2 on the days with dialysis. In HG2, after 24 weeks of the nutritional intervention, an increase in serum albumin (p = 0.0157) and a decrease in CRP concentration (p = 0.0306) were observed, whereas in HG1 there was a decrease in serum albumin concentration (p = 0.0043) with no significant change in CRP concentration. The nutritional intervention applied, called the Malnutrition-Eat Additional Meal (MEAM) diet with an easily digestible meal served before dialysis, was aimed at improving the patients' nutritional status and the obtained results indicate the need not only for substantial reeducation of hemodialysis patients in the area of their diet, but also for undertaking further research and discussions on the possibility of ensuring adequate meals for hemodialysis patients before the dialysis procedure.

Efficacy of Difelikefalin for the Treatment of Moderate to Severe Pruritus in Hemodialysis Patients: Pooled Analysis of KALM-1 and KALM-2 Phase 3 Studies.

Rationale & Objective: Chronic kidney disease-associated pruritus (CKD-aP) in patients treated by hemodialysis (HD) impairs quality of life (QoL). Difelikefalin, a selective κ-opioid receptor agonist, decreased the intensity of CKD-aP in patients undergoing HD. This pooled analysis evaluated difelikefalin's efficacy and the itch-related QoL overall and in subgroups defined by demographics or disease characteristics. Study Design: In KALM-1 and KALM-2, participants were randomized (1:1) to receive intravenous difelikefalin or placebo 3 times/wk for 12 weeks, followed by a 52-week open-label extension. Setting & Participants: Adults with moderate to severe CKD-aP treated by HD in North America, Europe, and the Asia-Pacific region. Intervention: Intravenous difelikefalin at 0.5 mcg/kg or placebo. Outcomes: Itch intensity (Worst Itching Intensity Numerical Rating Scale [WI-NRS]) and itch-related QoL (Skindex-10 and 5-D Itch questionnaires). Results: 851 participants were randomized (difelikefalin, n = 426; placebo, n = 425). This pooled analysis demonstrated early     (week 1), sustained difelikefalin efficacy, with significantly greater achievement of ≥3-point WI-NRS reduction with difelikefalin (51.1%) versus placebo (35.2%; P < 0.001). Achievement of a ≥4-point WI-NRS reduction was significantly greater with difelikefalin (38.7%) versus placebo (23.4%; P < 0.001). Difelikefalin reduced itch intensity in subgroups based on age, sex, anti-itch medication use, the presence of specific medical conditions, and gabapentin or pregabalin use. More participants receiving difelikefalin versus placebo achieved clinically meaningful decreases of ≥15 points on the Skindex-10 scale (55.5% vs 40.5%, respectively; P < 0.001) and ≥5 points on the 5-D Itch scale (52.1% vs 42.3%, respectively; P = 0.01), with sustained 5-D Itch effects up to 64 weeks. Limitations: Subgroup samples were small. The WI-NRS, Skindex-10, and 5-D Itch are not used in routine clinical care of dialysis patients; therefore, findings may not reflect the real-world effectiveness of difelikefalin. Conclusions: Difelikefalin demonstrated rapid, sustained efficacy, with consistent results in diverse populations of patients treated by HD. Funding: Cara Therapeutics, Inc. Trial Registration: The KALM-1 trial is registered as NCT03422653 and the KALM-2 trial is registered as NCT03636269.

[The influence of short-term magnesium carbonate treatment on calcium-phosphorus balance in dialysis patients]. / Wplyw krótkoterminowego leczenia weglanem magnezu na gospodarke wapniowo-fosforanowa u chorych przewlekle hemodializowanych.

INTRODUCTION: The phosphate-binders presently used in the treatment of calcium-phosphorus disorders in dialysis patients remain a crucial element of cardio-vascular protection. The aim of the study was to assess short-time magnesium carbonate treatment efficacy in hemodialysis patients with hyperphosphatemia. MATERIAL AND METHODS: The study involved 64 participants (32 male and 32 female) aged 29-84 years, with end-stage renal disease, hyperphosphatemia (> 1.78 mmol/l), dialysis 3 times a week, mean session time 4 hours 15 minutes. All the patients were divided into three groups: I--30 patients treated with magnesium carbonate 3 x 1 g; group II--10 patients treated with sevelamer hydrochloride 0.8 g--3 x 2 tabl (3 x 1.6 g); group III--24 patients treated with calcium carbonate 3 x 2 g. Participants were categorized randomly to groups I and II and to group III only patients with decreased serum calcium concentration (< 2.1 mmol/1) were assigned. The doses stayed constant within 12 weeks of therapy. RESULTS: In group treated with magnesium carbonate after 3 months of the treatment the decrease of plasma parathormon (iPTH) from 526.1 +/- 463.3 to 443.2 +/- 223.1 (pg/ml), calcium (Ca) from 2.4 +/- 0.2 to 2.3 +/- 0.1 (mmol/1); the highest reduction of phosphate (P) 2.1 +/- 0.5 to 1.6 +/- 0.4 (mmol/1) and calcium phosphate product (Cax P) from 4.6 +/- 2.3 to 3.5 +/- 1.1 (mmol2/ l2) were observed. In group II, iPTH slightly increased from initial 425.26 +/- 192.5 to 445.6 +/- 222.3 (pg/ml); serum calcium decreased from 2.23 +/- 0.17 to 2.0 +/- 0.2 (mmol/l); phosphates dropped from 2.35 +/- 0.43 to 2.0 +/- 0.3 (mmol/l) and Ca x P index from 5.1 +/- 1.2 to 4.1 +/- 0.7 (mmol2/l2). In group treated with calcium carbonate iPTH decreased from 308.2 +/- 196.6 to 301.9 +/- 188.5 (pg/ml). Calcium, phosphate and Ca x P dropped during the treatment from 2.06 +/- 0.23 to 2.05 +/- 0.2 (mmol/l), 2.17 +/- 0.36 to 1.86 +/- 0.45 (mmol/l) and from 4.7 +/- 0.8 to 3.7 +/- 0.9 (mmol2/l2), respectively. Calcium-phosphorus disorders were normalized to actual guidelines only in participants treated with magnesium carbonate. CONCLUSIONS: Magnesium carbonate seems to be the effective treatment of calcium-phosphorus disorders in hemodialysis patients. However its administration, similarly to other non-calcium phosphate-binders, is limited and dedicated to patients with normal serum calcium concentration.

[The assessment of cynacalcet (Mimpara) accompanied by alfacalcidol treatment efficacy in haemodialysis patients with different secondary hyperparathyroidism severity recognized by iPTH]. / Ocena skutecznosci cynakalcetu (Mimpara) i alfakalcydolu w leczeniu róznych stadiów zaawansowania wtórnej nadczynnosci przytarczyc monitorowanych stezeniami iPTH u chorych przewlekle hemodializowanych.

INTRODUCTION: Calcimimetics are highly efficient drugs in treatment of secondary hyperparathyroidism (sHPT) in patients on haemodialysis. The effect and the dose of cinacalcet may depend on severity of sHPT, and alfacalcidol supplementation helps in the treatment optimization. The study evaluated cinacalcet and alfacalcidol treatment efficacy in haemodialysis patients with different secondary hyperparathyroidism severity recognized by iPTH. MATERIAL AND METHODS: The study group comprised of 82 participants (male 67 and 34 female) in aged from 36 to 75 years, on haemodialysis. All patients were divided into two groups: the study group--40 participants treated with cinacalcet accompanied by alfacalcidol started after 8 months of the study (0.25 to 0.5 microg/day) and the control group--42 patients. The study group comprises of two subgroups: I--moderate sHPT with iPTH 500 to 800 pg/ml and II--severe sHPT with iPTH > 800 pg/ml. The basic phosphate binder treatment throughout the study period in all groups was calcium carbonate. RESULTS: In the subgroup I initial mean iPTH 700 +/- 129 pg/ml was reduced to 550 +/- 61 pg/ml (p < 0.05) in the third month with no need of the Mimpara dose change. No further iPTH decrease up to eighth month of the treatment was observed despite the cinacalcet dose increase to 53 mg (p < 0.05). The alfacalcidol supplementation decreased iPTH to 331 +/-55 pg/ml (p < 0.05) and the cynacalcet dose to 42 mg (p < 0.05). In the II subgroup iPTH was reduced from 1035 +/- 149 pg/ml to 885 +/- 101 pg/ml (p < 0.05) in the third month of the treatment and Mimpara dose changed to 90 mg. Up to eighth month iPTH did not change (790 +/- 92 pg/ml; p > 0.05) despite the cinacalcet dose increase to 122 mg (p < 0.05). The alfacalcidol supplementation induced iPTH reduction to 622 +/- 71 pg/ml (p < 0.05) and the cinacalcet dose to 100 mg (p < 0.05). CONCLUSIONS: Cinacalcet convinced its effectiveness in the iPTH serum concentration control in haemodialysis patients independently of secondary hyperparathyroidism severity and alfacalcidol supplementation enhanced its efficacy. Still in case of the late introduction of Mimpara this drug was recognized as potent however the efficient dose was mandatory multiply.

Serum microRNA profiles in patients with autosomal dominant polycystic kidney disease show systematic dysregulation partially reversible by hemodialysis.

INTRODUCTION: The impact of autosomal dominant polycystic kidney disease (ADPKD) on serum microRNAs (miRNA) is unknown. MATERIAL AND METHODS: For profiling experiment we recruited 30 patients from three equinumerous groups: controls, ADPKD and ADPKD on hemodialysis. From the last group extra samples were collected for in pre-/postdialysis analysis. Additionally, 23 healthy volunteers were used for selected biomarker verification. Real-time PCR arrays were used for quantification of 752 miRNAs. Validation of selected miRNAs was performed in total RNA extracted from the serum and the exosomal fraction in pre-/postdialysis samples. RESULTS: In total, 37 significant circulating miRNAs were found to differ between ADPKD patients and controls. In validation, 3 miRNAs with the highest fold change in comparison of dialyzed vs non-dialyzed patients (miR-532-3p, miR-320b, miR-144-5p) were not significantly altered by hemodialysis and from the top down-regulated ones, miR-27a-3p was significantly lower after dialysis in both total and exosomal fractions, miR-20a-5p was down-regulated in the exosomal fraction and miR-16-5p was unaltered by hemodialysis. MiR-16-5p was selected as the best circulating biomarker of ADPKD. Circulating representatives of the miR-17 family sharing the same seed region (miR-20a-5p, miR-93-5p and miR-106a-5p) showed significantly lower expression among dialyzed vs. non-dialyzed patients and their exosomal fraction dropped after hemodialysis. CONCLUSIONS: The serum miRNAs among ADPKD patients differ substantially depending on the stage of CKD. The exosomal fraction of miRNA was more affected by dialysis than the total one. There was a common pattern of down-regulation for circulating miR-17 family members sharing the same seed region.