Chronic Kidney Disease and Obesity.

There is a pandemic of obesity worldwide and in Europe up to 30% of the adult population is already obese. Obesity is strongly related to the risk of CKD, progression of CKD, and end-stage renal disease (ESRD), also after adjustment for age, sex, race, smoking status, comorbidities, and laboratory tests. In the general population, obesity increases the risk of death. In nondialysis-dependent CKD patients, the association between body mass index and weight with mortality is controversial. In ESRD patients, obesity is paradoxically associated with better survival. There are only a few studies investigating changes in weight in these patients and in most weight loss was associated with higher mortality. However, it is not clear if weight change was intentional or unintentional and this is an important limitation of these studies. Management of obesity includes life-style interventions, bariatric surgery, and pharmacotherapy. In the last 2 years, a long-acting glucagon-like peptide-1 (GLP-1) receptor agonist and GLP-1 and glucose-dependent insulinotropic polypeptide receptor agonist were shown to be effective in managing weight loss in non-CKD patients, but we are awaiting results of more definitive studies in CKD patients.

Early Detection of Arteriovenous Fistula Stenosis in Hemodialysis Patients through Routine Measurements of Dialysis Dose (Kt/V).

BACKGROUND: Monitoring of arteriovenous (AV) fistula to detect hemodynamically important stenosis is crucial for the prevention of AV fistula thrombosis. The aim of our study was to analyze the importance of dialysis dose (Kt/V) during online postdilution hemodiafiltration (HDF) for early detection of AV fistula stenosis. METHODS: Hemodialysis patients with AV fistula were included in this study. We compared a group of 44 patients who have undergone fistulography and subsequently percutaneous transluminal angioplasty (PTA) of significant AV fistula stenosis (active group) with a group of 44 age- and sex-matched patients without PTA (control group). Observational time in both groups was the same. RESULTS: All patients had postdilution online HDF using a F5008 dialysis machine, which can measure online single-pool Kt/V. All data were analyzed during the performance of 2056 HDF procedures. In the active group, we found statistically significantly lower values of Kt/V, all 8 weeks before PTA. In the active group, there was a significant improvement in Kt/V in the first (p < 0.001) and second week (p = 0.049) after PTA. Three and 8 weeks after PTA, we did not find any statistically significant difference in Kt/V between both groups (p = 0.114; p = 0.058). Patients in the active group had statistically significantly lower substitution volumes and blood pump flow rates during HDF over the whole observation period before and after PTA. In contrast, there were no differences in venous pressure in the dialysis circuit between both groups throughout the observation period. CONCLUSION: In hemodialysis patients with AV fistula, treated with online HDF, routine measurements of Kt/V during each HDF are a beneficial, quick, and straightforward method for early detection of hemodynamically significant AV fistula stenosis.

Assessment of volume status with bioimpendance prior to hemodialysis and its importance for predicting survival in hemodialysis patients.

BACKGROUND: Optimal fluid management is a physician's everyday challenge in patients on maintenance hemodialysis (HD). Bioimpedance spectroscopy (BIS) is a non-invasive method to estimate body composition, including estimates of fluid overload (FO). Our study aimed to analyze the association between FO and the mortality rate in HD patients. MATERIALS AND METHODS: We performed a retrospective single-center cohort study in 92 HD patients. The body composition was measured before HD using the portable whole-body BIS device Body Composition Monitor (BCM). We have analyzed the mortality rates of HD patients in two FO groups, a standard definition FO group (> 1.1 L), and a severe FO group (> 2.5 L) and compared them to mortality rates of patients without FO or without severe FO, respectively. RESULTS: The mean age of patients was 64.3 ± 13.0 years, mean dialysis vintage 64 months, 60.9% were men. 68 (73.9%) patients had FO of > 1.1 L and 30 (32.6%) had FO of > 2.5 L. During the follow-up period of 1,020 ± 417 days, 29 (31.5%) patients died. Kaplan-Meier survival analysis showed that patients with FO > 2.5 L had worse survival (p = 0.039). In a Cox regression model, which included FO > 2.5 L, age, dialysis vintage, hemoglobin, C-reactive protein, and albumin, only FO > 2.5 L and advanced age turned out to be predictors of death (p = 0.044 and p = 0.001, respectively). CONCLUSION: HD patients with FO > 2.5 L before HD have poorer survival than patients with normohydration or lower overhydration.

Association between lung comets and subendocardial viability ratio in peritoneal dialysis patients.

AIMS: Pulmonary congestion is a direct result of either general overhydration or cardiac dysfunction. Lung ultrasonography (LUS) with lung B-lines (LUS comets) can be used to assess extravascular lung water in patients with end-stage renal disease on hemodialysis or peritoneal dialysis (PD). Subendocardial viability ratio (SEVR) is a pulse wave analysis parameter that is a non-invasive measure of coronary perfusion and is related to cardiac work and oxygen consumption. Our aim was to investigate the association between LUS comets and SEVR in PD patients. MATERIALS AND METHODS: We performed an observational study in 25 PD patients in a single dialysis center. Extravascular lung water was quantified by the number of LUS comets, using a portable ultrasound (US) device. LUS comets were recorded in each intercostal space and defined as hyperechoic US bundles at a narrow base extending from the transducer to the edge of the screen. The sum of LUS comets yields a score reflecting the extent of water accumulation in the lungs. SEVR was determined non-invasively by radial applanation tonometry. RESULTS: Mean age of patients was 54.7 ± 10.7 years, mean PD vintage 27 ± 33 (1 - 167) months, 60% were men. The mean number of LUS comets was 13 ± 19 (0 - 71), and the mean SEVR was 153 ± 40%. We found a statistically significant negative correlation between the number of LUS comets and SEVR (r = -0.467; p = 0.019). Multiple regression analysis with LUS comets as dependent variable, and SEVR and age as independent variables showed a statistically significant relationship between SEVR and the number of LUS comets (ß = -0.467, p = 0.021). CONCLUSION: Higher number of LUS comets is associated with lower SEVR in PD patients.

Lung ultrasound, hemoglobin, and NT-proBNP in peritoneal dialysis patients.

BACKGROUND: Lung ultrasound (LUS) is a non-invasive technique for estimating extravascular lung water in patients with end-stage renal disease and heart diseases. In this study, we examined an association between the severity of lung congestion as detected by LUS B-lines (LUS comets), anemia, and serum biomarker N-terminal pro-brain natriuretic peptide (NT-proBNP) in peritoneal dialysis (PD) patients. MATERIALS AND METHODS: 19 patients, who were treated with PD in our dialysis center were enrolled. On the day of their routine check-up, we performed a lung auscultation, LUS on 28 typical locations and determined blood levels of hemoglobin and NT-proBNP. RESULTS: The average age of patients was 54 (range 30 - 71) years, the average duration of PD treatment was 53 (range 10 - 194) months, 63% (12) of the patients were male. Nine (47.4%) patients had peripheral edema, and only 1 (5.3%) patient had inspiratory crackles. Using LUS, we found mean 17 (range 1 - 87) lung comets. Mean hemoglobin level was 108.6 g/L (SD ± 10.4), mean NT-proBNP level 1,151 pmol/L (SD ± 1,077). We found a statistically significant correlation between the number of lung comets and hemoglobin level (r = -0.655; p = 0.002) and NT-proBNP (r = 0.759; p < 0.0001). Multiple regression analysis with the number of lung comets as dependent variable and hemoglobin and NT-proBNP levels as independent variables confirmed a statistically significant association between the number of lung comets and NT-proBNP (ß = 0.572; p = 0.009). CONCLUSION: In PD patients, the number of LUS comets is associated with hemoglobin and NT-proBNP.

Mineralocorticoid Receptor Antagonists in Diabetic Kidney Disease.

Diabetes mellitus is a global health issue and main cause of chronic kidney disease. Both diseases are also linked through high cardiovascular morbidity and mortality. Diabetic kidney disease (DKD) is present in up to 40% of diabetic patients; therefore, prevention and treatment of DKD are of utmost importance. Much research has been dedicated to the optimization of DKD treatment. In the last few years, mineralocorticoid receptor antagonists (MRA) have experienced a renaissance in this field with the development of non-steroidal MRA. Steroidal MRA have known cardiorenal benefits, but their use is limited by side effects, especially hyperkalemia. Non-steroidal MRA still block the damaging effects of mineralocorticoid receptor overactivation (extracellular fluid volume expansion, inflammation, fibrosis), but with fewer side effects (hormonal, hyperkalemia) than steroidal MRA. This review article summarizes the current knowledge and newer research conducted on MRA in DKD.

Diabetic patients with chronic kidney disease: Non-invasive assessment of cardiovascular risk.

The prevalence and burden of diabetes mellitus and chronic kidney disease on global health and socioeconomic development is already heavy and still rising. Diabetes mellitus by itself is linked to adverse cardiovascular events, and the presence of concomitant chronic kidney disease further amplifies cardiovascular risk. The culmination of traditional (male gender, smoking, advanced age, obesity, arterial hypertension and dyslipidemia) and non-traditional risk factors (anemia, inflammation, proteinuria, volume overload, mineral metabolism abnormalities, oxidative stress, etc.) contributes to advanced atherosclerosis and increased cardiovascular risk. To decrease the morbidity and mortality of these patients due to cardiovascular causes, timely and efficient cardiovascular risk assessment is of huge importance. Cardiovascular risk assessment can be based on laboratory parameters, imaging techniques, arterial stiffness parameters, ankle-brachial index and 24 h blood pressure measurements. Newer methods include epigenetic markers, soluble adhesion molecules, cytokines and markers of oxidative stress. In this review, the authors present several non-invasive methods of cardiovascular risk assessment in patients with diabetes mellitus and chronic kidney disease.

CHA2DS2-VASc Score as a Predictor of Cardiovascular and All-Cause Mortality in Chronic Kidney Disease Patients.

INTRODUCTION: Chronic kidney disease (CKD) is a risk factor for cardiovascular and all-cause mortality. Recognition of high-risk patients is important and could lead to a different approach and better treatment. The CHA2DS2-VASc score was originally used to predict cerebral infarction in patients with atrial fibrillation (AF), but it is also a useful predictor of outcome in other cardiovascular conditions, independent of AF. Therefore, the aim of our research was to assess the role of CHA2DS2-VASc score in predicting cardiovascular and all-cause mortality in CKD patients. METHODS: Stable nondialysis CKD patients were included. At the time of inclusion, medical history data and standard blood results were collected and CHA2DS2-VASc score was calculated. Patients were followed till the same end date, until kidney transplantation or until their death. RESULTS: Eighty-seven CKD patients were included (60.3 ± 12.8 years, 66% male). Mean follow-up time was 1,696.5 ± 564.6 days. During the follow-up, 21 patients died and 11 because of cardiovascular reasons. Univariate Cox regression analysis showed that CHA2DS2-VASc score is a significant predictor of cardiovascular and all-cause mortality. In multivariate Cox regression analysis, in which CHA2DS2-VASc score, serum creatinine, urinary albumin/creatinine, hemoglobin, high-sensitivity C-reactive protein, and intact parathyroid hormone were included, CHA2DS2-VASc score was an independent predictor of cardiovascular (HR: 2.04, CI: 1.20-3.45, p = 0.008) and all-cause mortality (HR: 2.06, CI: 1.43-2.97, p = 0.001). The same was true after adding total cholesterol, triglycerides, and smoking status to both the analyses. CONCLUSION: The CHA2DS2-VASc score is a simple, practical, and quick way to identify the risk for cardiovascular and all-cause mortality in CKD patients.

Oxidative Stress Markers in Chronic Kidney Disease with Emphasis on Diabetic Nephropathy.

Diabetes prevalence is increasing worldwide, especially through the increase of type 2 diabetes. Diabetic nephropathy occurs in up to 40% of diabetic patients and is the leading cause of end-stage renal disease. Various factors affect the development and progression of diabetic nephropathy. Hyperglycaemia increases free radical production, resulting in oxidative stress, which plays an important role in the pathogenesis of diabetic nephropathy. Free radicals have a short half-life and are difficult to measure. In contrast, oxidation products, including lipid peroxidation, protein oxidation, and nucleic acid oxidation, have longer lifetimes and are used to evaluate oxidative stress. In recent years, different oxidative stress biomarkers associated with diabetic nephropathy have been found. This review summarises current evidence of oxidative stress biomarkers in patients with diabetic nephropathy. Although some of them are promising, they cannot replace currently used clinical biomarkers (eGFR, proteinuria) in the development and progression of diabetic nephropathy.

Progression of endothelial dysfunction, atherosclerosis, and arterial stiffness in stable kidney transplant patients: a pilot study.

BACKGROUND: Kidney transplant patients suffer from vascular abnormalities and high cardiovascular event rates, despite initial improvements post-transplantation. The nature of the progression of vascular abnormalities in the longer term is unknown. This pilot study investigated changes in vascular abnormalities over time in stable kidney transplant patients long after transplantation. METHODS: Brachial artery flow-mediated dilation (FMD), nitroglycerin-mediated dilation, carotid-femoral pulse wave velocity (cf-PWV), ankle-brachial pressure index, and common carotid artery intima-media thickness (CCA-IMT) were assessed in 18 kidney transplant patients and 17 controls at baseline and 3-6 months after. RESULTS: There was no difference in age (51 ± 13 vs. 46 ± 11; P = 0.19), body mass index (26 ± 5 vs. 25 ± 3; P = 0.49), serum cholesterol (4.54 ± 0.96 vs. 5.14 ± 1.13; P = 0.10), systolic blood pressure (BP) (132 ± 12 vs. 126 ± 12; P = 0.13), diastolic BP (82 ± 9 vs. 77 ± 8; P = 0.10), or diabetes status (3 vs. 0; P = 0.08) between transplant patients and controls. No difference existed in vascular markers between patients and controls at baseline. In transplant patients, FMD decreased (- 1.52 ± 2.74; P = 0.03), cf-PWV increased (0.62 ± 1.06; P = 0.03), and CCA-IMT increased (0.35 ± 0.53; P = 0.02). No changes were observed in controls. CONCLUSION: Markers of vascular structure and function worsen in the post-transplant period on long-term follow-up, which may explain the continued high cardiovascular event rates in this population.

Ambulatory Hemodialysis-Technology Landscape and Potential for Patient-Centered Treatment.

CKD is a worldwide health problem and the number of patients requiring kidney replacement therapy is rising. In the United States, most patients with ESKD rely on in-center hemodialysis, which is burdensome and does not provide the same long-term benefits as kidney transplantation. Intensive hemodialysis treatments have demonstrated improved clinical outcomes, but its wider adoption is limited by equipment complexity and patient apprehension. Ambulatory devices for hemodialysis offer the potential for self-care treatment outside the clinical setting as well as frequent and prolonged sessions. This article explains the motivation for ambulatory hemodialysis and provides an overview of the necessary features of key technologies that will be the basis for new wearable and implantable devices. Early work by pioneers of hemodialysis is described followed by recent experience using a wearable unit on patients. Finally, ongoing efforts to develop an implantable device for kidney replacement and its potential for implantable hemodialysis are presented.

Cystatin C as a predictor of mortality in elderly patients with chronic kidney disease.

BACKGROUND: The prevalence of chronic kidney disease (CKD) in the elderly is high. Serum cystatin C is an accurate marker of kidney function and it also has prognostic utility in CKD patients. The aim of our study was to determine the prediction of serum cystatin C and other markers of kidney function on long-term survival in elderly CKD patients. METHODS: Fifty eight adult Caucasian patients, older than 65 years, without known malignancy, thyroid disease and/or not on steroid therapy were enrolled in the study. In each patient, 51CrEDTA clearance, serum creatinine, serum cystatin C, and estimated glomerular filtration rate using different equations were determined on the same day and patients were then followed for 11 years or until their death. RESULTS: The means are as follows: 51CrEDTA clearance 53.3 ± 17.4 ml/min/1.73 m2, serum creatinine 1.62 ± 0.5 mg/dl, serum cystatin C 1.79 ± 0.5 mg/l, Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation 40.1 ± 14 ml/min/1.73 m2, Berlin Initiative Study 2 (BIS2) equation 38.9 ± 10.7 ml/min/1.73 m2, full age spectrum (FAS) creatinine equation 43.8 ± 13.8 ml/min/1.73 m2, FAS cystatin C equation 40.1 ± 11.7 ml/min/1.73 m2. In the follow up period, 47 (81%) patients died. Cox regression analysis showed different hazard ratios (HRs) for death: for 51CrEDTA clearance HR 1.022 (95% CI 1.004-1.042; p = .015), serum creatinine HR 1.013 (95% CI 1.006-1.019; p = .001), serum cystatin C HR 2.028 (95% CI 1.267-3.241; p = .003), CKD-EPI creatinine equation HR 1.048 (95% CI 1.019-1.076; p = .001), BIS2 equation HR 1.055 (95% CI 1.021-1.088; p = .001), FAS creatinine equation HR 1.046 (95% CI 1.017-1.074; p = .001), FAS cystatin C equation HR 1.039 (95% CI 1.010-1.071; p = .009). CONCLUSIONS: Our results showed the highest HR for serum cystatin C among kidney function markers for prediction of outcome in elderly CKD patients.

Derived Subendocardial Viability Ratio and Cardiovascular Events in Patients with Chronic Kidney Disease.

BACKGROUND: Chronic kidney disease (CKD) is a well-known mortality risk factor. The subendocardial viability ratio (SEVR) is one of the pulse wave analysis parameters that constitutes a non-invasive measure of coronary perfusion. We aimed to assess the prognostic value of the SEVR for cardiovascular outcome in non-dialysis CKD patients. METHODS: A total of 98 CKD patients (mean age 60 years) were prospectively followed up from the date of the SEVR measurement until their death or the start of dialysis/transplantation, maximally up to 7.1 years (mean 5 years). According to the manufacturer's instructions regarding normal SEVR values, the patients were divided into a low SEVR group (SEVR ≤130%, n = 26) and a normal SEVR group (SEVR > 130%, n = 72). RESULTS: During the follow-up period, 13 patients (13.3%) suffered fatal and 23 patients (23.5%) suffered combined (non-fatal and fatal) cardiovascular events. In the patients who died of cardiovascular causes, the SEVR values were statistically significantly lower (130 vs. 154%; p = 0.017) than in those who survived. A Kaplan-Meier survival analysis showed that the cardiovascular survival rate in the low SEVR group of patients was statistically significantly lower (log-rank test: p < 0.001). Using an unadjusted Cox regression analysis, the patients in the low SEVR group had a 5.6-fold higher risk (95% CI: 1.8-17.3; p = 0.002) of fatal cardiovascular events and a 2.7-fold higher risk (95% CI: 1.1-6.3; p = 0.024) of combined fatal and non-fatal cardiovascular events. In the adjusted Cox regression model, the patients in the low SEVR group had a 16-fold higher risk (95% CI: 1.2-9.7; p = 0.004) of fatal cardiovascular events and a 7-fold higher risk (95% CI: 1-9.7; p = 0.009) of combined fatal and non-fatal cardiovascular events. CONCLUSIONS: An SEVR < 130% predicts fatal and non-fatal cardiovascular events in non-dialysis CKD patients.

Measurement of breath ammonia for detection of patients with chronic kidney disease.

BACKGROUND: In a healthy individual, ammonia is converted to urea in the liver. Urea is then transported through the bloodstream and then excreted into the urine by the kidneys. In patients with chronic kidney disease (CKD), the accumulated urea is degraded by salivary urease into ammonia, which is then excreted by breathing. Breath ammonia can therefore be used for detecting the increased nitrogen-bearing wastes. In our pilot study, an electrochemical sensor was used to measure and analyze breath ammonia in healthy volunteers and patients with CKD. PATIENTS AND METHODS: In our study, 8 patients with CKD (stages 4 and 5) and 6 healthy volunteers were enrolled. All participants were nonsmokers and without pulmonary or liver disease. One controlled breath sample was collected from each participant. Immediately after the sample was collected, a gas analyzer was used for measuring breath ammonia in our participants. RESULTS: Mean creatinine value of CKD patients was 455.2 ± 294.1 µmol/L and 62.1 ± 7.5 µmol/L for healthy volunteers. Breath ammonia levels (3.32 ± 2.19 ppm vs. 0.49 ± 0.08 ppm; p = 0.003) and measured electric current (4.33 ± 0.25 mA vs. 4.01 ± 0.01 mA; p = 0.003) were significantly higher in the CKD group. CONCLUSIONS: The results of our pilot study show that breath monitoring of ammonia can be a simple, useful, fast, and noninvasive tool for detection of advanced kidney impairment.
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Relationship between subendocardial viability ratio and hemoglobin in patients with chronic kidney disease.

AIMS: Pulse wave analysis (PWA) uses the technique of applanation tonometry to obtain a peripheral pulse pressure waveform from which central hemodynamic information is derived. Using PWA, subendocardial viability ratio (SEVR) can be measured. SEVR represents a noninvasive measure of myocardial perfusion. It is related to the work of the heart, the oxygen consumption, and the energy supply of the heart. Anemia is a common complication of chronic kidney disease (CKD). A complex relationship exists between CKD, cardiovascular disease (CVD), and anemia. The aim of our study was to assess the relationship between SEVR and hemoglobin in non-dialysis CKD patients. MATERIAL AND METHODS: We examined the associations between PWA hemodynamic parameters, 24-hour ambulatory blood pressure (BP) measurements, and laboratory variables including hemoglobin, cardiac biomarkers troponin I, NT-proBNP, and hs-CRP in a cohort of 91 nondialysis CKD patients. PWA was assessed by radial applanation tonometry (SphygmoCor, Atcor, Sydney, Australia). The patients were divided into two groups according to the median value of hemoglobin. RESULTS: Mean age of included patients was 60.2 years, 67% were men, 44% were smokers, 25.3% had diabetes. A significant correlation between hemoglobin and SEVR was found (r = 0.26; p = 0.012). With multivariate regression analysis, SEVR as dependent variable turned out to be statistically significantly associated with hemoglobin (ß = 0.344, p = 0.013) and with troponin I (ß = -0.217, p = 0.037). Patients in the group with lower hemoglobin had statistically-significantly higher serum creatinine, cystatin C, NT-proBNP, and 24-hour ambulatory systolic BP and lower e-GFR, SEVR, and office diastolic BP. CONCLUSIONS: Results of our study show that SEVR is independently associated with hemoglobin in nondialysis CKD patients. CKD patients with lower hemoglobin have lower SEVR.
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Estimation of Glomerular Filtration Rate in Elderly Chronic Kidney Disease Patients: Comparison of Three Novel Sophisticated Equations and Simple Cystatin C Equation.

Estimating glomerular filtration rate (GFR) in elderly patients is a problem, since they are poorly represented in studies developing GFR equations. Serum cystatin C is a better indicator of GFR than serum creatinine in elderly patients. Therefore the aim of our study was to compare frequently used serum cystatin C based GFR equations with a gold standard (51 CrEDTA clearance) in elderly chronic kidney disease (CKD) patients. 106 adult Caucasian patients, older than 65 years (58 women, 48 men; mean age 72.5 years), were included. In each patient 51 CrEDTA clearance, serum creatinine (IDMS traceable method) and serum cystatin C (immunonephelometric method) were determined. GFR was estimated using the Simple cystatin C, CKD-EPI cystatin C, CKD-EPI creatinine-cystatin C and BIS2 equation. Mean serum creatinine of our patients was 141.4 ± 41.5 µmol/L, mean serum cystatin C 1.79 ± 0.6 mg/L, mean 51 CrEDTA clearance was 52.2 ± 15.9 mL/min per 1.73 m2 . Statistically significant correlations between 51 CrEDTA clearance and all formulas were found (P < 0.0001). In the receiver operating characteristic (ROC) curve analysis (cut-off for GFR 45 mL/min per 1.73 m2 ) no significant differences in diagnostic accuracy between all the before mentioned equations were found. Bland-Altman analysis for the same cut-off showed that CKD-EPI creatinine-cystatin C and BIS2 equation underestimated and CKD-EPI cystatin C and Simple cystatin C equation overestimated measured GFR. All equations lacked precision. Analysis of ability to correctly predict patient's GFR below or above 45 mL/min per 1.73 m2 showed similar ability for all equations (P = 0.24-0.89). All equations are equally accurate for estimating GFR in elderly Caucasian CKD patients. For daily practice Simple cystatin C equation is most practical.

Markers of Inflammation and Oxidative Stress in the Development and Progression of Renal Disease in Diabetic Patients.

The prevalence of diabetes is increasing and has already reached pandemic proportions. Diabetes is a well-known risk factor for chronic kidney disease. Diabetic kidney disease (DKD) occurs in up to 40% of people with type 1 or 2 diabetes and is nowadays the leading cause of end-stage renal disease (ESRD). Among several factors involved in the development and progression of DKD are also inflammation and oxidative stress. Unfortunately, there is a paucity of sensitive and specific biomarkers for the early prediction of patients who will develop DKD or will progress to ESRD. This review summarizes the evidence regarding the prognostic value and benefits of targeting markers of inflammation (pro-inflammatory cytokines, tumour necrosis factor-α (TNF-α) and TNF-α receptors, adhesion molecules, chemokines) and markers of oxidative stress. Some of these biomarkers are promising, but further studies are needed before they can be used in clinical practice.

Subendocardial Viability Ratio Is Impaired in Highly Proteinuric Chronic Kidney Disease Patients With Low Estimated Glomerular Filtration Rate.

Proteinuria and estimated glomerular filtration rate (eGFR) are markers of chronic kidney disease (CKD) and cardiovascular disease. With applanation tonometry, pulse wave analysis and many hemodynamic data are available. One of them is the subendocardial viability ratio (SEVR) which represents a non-invasive measure of myocardial perfusion related to the work of the heart. The aim of our study was to investigate the importance of SEVR in proteinuric CKD patients and healthy subjects. We performed a cross-sectional study in a cohort of 90 non-dialysis CKD patients and 39 healthy controls. SEVR was assessed by radial applanation tonometry (SphygmoCor, Atcor, Australia). Blood samples and urine albumin-to-creatinine ratio (UACR) were analyzed. CKD patients were divided in four groups according to the UACR and eGFR: CKD group 1: UACR > 1000 mg/g and eGFR < 30 mL/min; CKD group 2: UACR > 1000 mg/g and eGFR >30 mL/min; CKD group 3: UACR <1000 mg/g and eGFR < 30 mL/min and CKD group 4: UACR < 1000 mg/g and eGFR >30 mL/min. Using one-way ANOVA, we found a statistically significant difference in SEVR only between CKD group 1 and all other CKD groups and healthy control group (P < 0.022). Results of our study show that only CKD patients with UACR more than 1000 mg/g and eGFR below 30 mL/min have significantly lower SEVR.

Ankle-Brachial Index and Long-Term (10 Years) Survival of Nondiabetic Hemodialysis Patients.

Low (<0.9) and high (>1.4) ankle brachial index (ABI) is associated with a higher cardiovascular (CV) mortality in the general and hemodialysis (HD) population. The aim of our study was to determine the impact of ABI on long-term survival of 52 non-diabetic HD patients. The ABI was determined using an automated, non-invasive waveform analysis device. Patients were divided into three groups: low (<0.9), normal (0.9-1.4) and high (>1.4) ABI. Patients were observed from the date of ABI measurement until their death or ten years. Survival analysis showed higher risk for CV death in HD patients with high ABI compared to normal ABI (log rank test P < 0.027). In Cox regression model adjusted for arterial hypertension, smoking, serum cholesterol and triglycerides, high ABI (P < 0.049) remained a predictor of mortality. The results indicate an association between ABI and long-term survival of non-diabetic HD patients and only high ABI was associated with higher CV mortality.

Proteinuria and Albuminuria During and After Paricalcitol Treatment in Chronic Kidney Disease Patients.

Data on paricalcitol lowering albuminuria and proteinuria already exist; however, it is unclear how paricalcitol withdrawal affects both. Forty-two nondialysis chronic kidney disease (CKD) patients (29 men) aged 62.3 ± 12 years completed the study. CKD patients with proteinuria and intact parathyroid hormone ≥65 pg/mL received paricalcitol (1 µg/day po) for 6 months. After paricalcitol withdrawal we followed them for 6 more months. Paricalcitol treatment significantly reduced urinary albumin/creatinine ratio (UACR), 24-hour albuminuria (24hA), and 24-hour proteinuria (24hP). Six months after drug withdrawal UACR increased significantly, 24hA and 24hP did not change significantly. Serum creatinine and cystatin C significantly increased during treatment, and estimated glomerular filtration rate (eGFR) decreased. After drug withdrawal serum creatinine, cystatin C, and eGFR did not change significantly. In conclusion, 6-month paricalcitol treatment (1 µg/day) in nondialysis CKD patients significantly reduced albuminuria and proteinuria. Six months after paricalcitol withdrawal 24hA and 24hP did not change significantly. Kidney function decreased during paricalcitol treatment; after paricalcitol withdrawal it remained stable. The unaltered values of 24hA, 24hP, and kidney function after paricalcitol withdrawal could be a delayed effect of paricalcitol treatment.