Risk factors associated with mortality among patients on maintenance hemodialysis: The Thailand Renal Replacement Therapy registry.

INTRODUCTION: End-stage kidney disease (ESKD) has been increasing in prevalence across the world, including Thailand, and patients with ESKD on hemodialysis have a high mortality risk. METHODS: A retrospective cohort study was performed across 855 hemodialysis centers in the Thailand Renal Replacement Therapy registry. The database and mortality data were analyzed. RESULTS: A total of 58 952 patients were included. The survival rates at 1, 3, and 5 years were 93.5%, 69.7%, and 41.2%, respectively. On multivariate analysis, factors such as aging, permanent catheter or arteriovenous graft, twice-weekly hemodialysis, low levels of urea reduction ratio, normalized protein catabolic rate, hemoglobin, transferrin saturation, serum albumin, LDL-cholesterol, intact-parathyroid hormone, uric acid, sodium, phosphate, and bicarbonate were significantly related to death. CONCLUSION: Mortality is high in ESKD patients on hemodialysis. Age, type of vascular access, twice-weekly hemodialysis, inadequate dialysis, low protein intake, anemia, abnormal electrolytes, and bone mineral disorders are associated with all-cause mortality.

Effect of intradialytic weight resistance training exercise in sarcopenic hemodialysis patients: A randomized controlled trial.

BACKGROUND: Sarcopenia has a high prevalence in end-stage kidney disease (ESKD). However, there is limited evidence of resistance exercise in these patients. OBJECTIVE: The study investigated the effects of resistance exercise on muscle mass, strength, and physical functioning. METHOD: Fifty-three patients were randomly assigned to resistance training exercise (n = 26) and standard exercise (n = 27) groups. All of the patients were diagnosed with sarcopenia by the Asian Working Group for Sarcopenia 2019 criteria. RESULTS: After 12 weeks, an improvement in leg muscle strength was significantly greater in the resistant exercise group compared with standard exercise (12.19 vs. 2.83 kg, p < 0.001). Appendicular skeletal muscle mass had a mean difference (1.01 vs. 1.02 kg/m2 , p = 0.96). Physical performance status had a mean difference (-2.3 vs. -18 s, p = 0.42). There were no serious adverse events. CONCLUSION: Over a 12-week follow-up, resistance exercise improved muscle strength in sarcopenic ESKD patients. Muscle mass and physical performance showed no significant change, but there is still a trend demonstrating to improve.

Effects of febuxostat on markers of endothelial dysfunction and renal progression in patients with chronic kidney disease.

Hyperuricemia relates to chronic kidney disease (CKD) progression and impaired endothelial function. Febuxostat is potent and effective for decreasing serum uric acid levels. Information for the effect of febuxostat treatment on markers of endothelial dysfunction and renal injury among patients with CKD remains limited. A total of 84 patients with CKD stages III-IV with asymptomatic hyperuricemia were randomly assigned to either the febuxostat (40 mg/day, N = 42) or the matching control (N = 42) group for 8 weeks. Serum asymmetric dimethylarginine (ADMA), estimated glomerular filtration rate (eGFR), urine albumin, high sensitivity C-reactive protein (hs-CRP), ankle brachial index (ABI) and serum uric acid were measured at baseline and at the end of study. Febuxostat administration significantly reduced the serum uric acid concentration among patients with CKD when compared with control [- 3.40 (95% CI - 4.19 to - 2.62) vs. - 0.35 (95% CI - 0.76 to 0.06) mg/dL; P < 0.001, respectively). No significant difference in the changes in serum ADMA, hs-CRP, eGFR and albuminuria was identified between the two groups. Subgroup analysis among patients with decreased serum uric acid after febuxostat, the estimated GFR change between the febuxostat and the control group showed significant difference at 8 weeks (2.01 (95% CI 0.31 to 3.7) vs. 0.04 (95% CI - 1.52 to 1.61) mL/min/1.73 m2; P = 0.030, respectively). Adverse events specific to febuxostat were not observed. Febuxostat effectively reduced serum uric acid in the CKD population without improving endothelial dysfunction. It was able to preserve renal function in the subgroup of patients with CKD and lower serum uric acid level after treatment.Trial registration: Thai Clinical Trials, TCTR20210224005: 24/022021 http://www.thaiclinicaltrials.org/show/TCTR20210224005 .

Effect of pioglitazone on serum FGF23 levels among patients with diabetic kidney disease: a randomized controlled trial.

AIM: Elevated fibroblast growth factor-23 (FGF23) is an established marker of cardiovascular disease among patients with type 2 diabetes (T2DM) and chronic kidney disease (CKD). Recently, circulating FGF23 positively correlated with insulin resistance level among patients with CKD. Pioglitazone improves insulin sensitivity and it may have potential for treating CKD-related FGF23 overactivity. METHODS: A randomized, open-label, controlled trial was performed among patients with T2DM and CKD. Eligible participants were randomly assigned to either oral 15 mg/day of pioglitazone (N = 22) or control group (N = 24) for 16 weeks. Serum FGF23 and homeostatic Model Assessment of Insulin Resistance (HOMA-IR) were measured. RESULTS: Forty-six patients completed the trial. After 16 weeks of treatment, significant decreases in serum intact FGF23 level (median change - 49.01 (IQR, - 103.51 to - 24.53) vs. 1.07 (IQR, - 22.4-39.53) pg/mL, P = 0.01) and HOMA-IR (mean change - 1.41 (95% CI, - 2.24 to - 0.57) vs. - 0.05 (95% CI, - 1.00-0.89), P = 0.031) were observed in the pioglitazone group compared with the control group. HemoglobinA1C also significantly decreased in the pioglitazone group compared with the control group. No difference was found in the changes of serum phosphorus, calcium and serum intact parathyroid hormone between the two groups. Changes of FGF23 were positively associated with changes of HOMA-IR (R = 0.47) and insulin levels (R = 0.47). No serious adverse event was reported during the study. CONCLUSION: This study confirmed that pioglitazone effectively reduced serum FGF23 levels and related to improved insulin sensitivity among patients with T2DM and CKD. CLINICAL TRIAL REGISTRATION: TCTR20210316009.

Efficacy of high versus conventional dose of ergocalciferol supplementation on serum 25-hydroxyvitamin D and interleukin-6 levels among hemodialysis patients with vitamin D deficiency: A multicenter, randomized, controlled study.

Long-term dialysis involves a chronic inflammatory state and produces a high prevalence of vitamin D deficiency. A clinical trial was conducted in hemodialysis with serum 25-hydroxyvitamin D (25[OH]D) level <30 ng/ml. The conventional-group (N = 35) and the high-dose group (N = 35) were treated with ergocalciferol according to the K/DOQI guidelines and double dosage of ergocalciferol from the recommendation for 8 weeks, respectively. The main outcomes were measured by serum 25[OH]D and interleukin-6 (IL-6). At the end of 8 weeks, a statistically significant greater increase was observed of mean serum 25[OH]D levels and a decrease of mean parathyroid hormone levels in the high-dose group compared with the conventional-dose group. The high dose group had the higher achievement of vitamin D sufficiency than the conventional-dose group (97.4% vs. 76.4%, p = 0.012). No significant difference was found in mean changes of serum IL-6 level in both groups, except subgroup patients with vitamin D deficiency or serum 25[OH]D <20 ng/ml, high dose treatment suppressed serum IL-6 level (-2.67 pg/ml [IQR -6.56 to -0.17], p = 0.039). No differences were observed between the two groups in adverse events. Oral high-dose ergocalciferol supplementation has achieved higher vitamin D sufficiency than standard dose in end stage renal disease patients on dialysis.

Effect of senna glycoside on serum potassium levels among patients on maintenance hemodialysis: A randomized controlled trial.

BACKGROUND: Hyperkalemia is common among end-stage renal disease (ESRD) patients, and consequently contributes to an increased risk of cardiac arrhythmia. Senna glycoside may decrease colonic transit time and potassium colonic reabsorption. METHODS: Patients on hemodialysis were randomized to receive either oral senna glycoside (n = 37) or control (n = 36) for 8 weeks. The primary outcomes were predialysis serum potassium and prevalence of hyperkalemia. RESULTS: At the end of the study, significantly reduced serum potassium concentrations were observed in the senna glycoside compared with the control (-0.32 [95%CI -0.43, -0.04] vs. -0.02 [95%CI -0.12, 0.05] mEq/L, p < 0.001, respectively). The prevalence of hyperkalemia during the study occurred at 13.8% in the control and 5.4% in the senna glycoside (p = 0.309). No serious adverse events were observed. CONCLUSION: Among patients with ESRD on hemodialysis, senna glycoside significantly decreases serum potassium level. Senna glycoside is a safe and possibly effective alternative treatment for hyperkalemia in ESRD.

Efficacy of Lactulose versus Senna Plus Ispaghula Husk Among Patients with Pre-Dialysis Chronic Kidney Disease and Constipation: A Randomized Controlled Trial.

BACKGROUND: Constipation is a common problem among patients with advanced chronic kidney disease (CKD), leading to a loss of quality of life. Pharmacologic treatments are in common use, but whether lactulose and senna plus ispaghula husk is effecive to treat constipation among patients with pre-dialysis CKD remains unknown. OBJECTIVE: The aim of the study was to compare efficacy of lactulose and senna plus ispaghula husk to treat constipation among patients with pre-dialysis CKD. METHODS: A study was conducted among patients with pre-dialysis CKD receiving a diagnosis of constipation by ROME IV criteria. All subjects were randomly assigned to receive either lactulose or senna plus ispaghula husk daily for 14 days. After a 7-day washout period, the patients were switched to the other substance for another 14 days. Primary outcome was complete spontaneous bowel movement (CSBM) weekly, assessed using a stool diary after each laxative. Secondary outcome measure was the change of stool appearance using the Bristol stool form scale (BSFS). RESULTS: A total of 22 patients underwent randomization. Baseline CSBM and BSFS were 3.4 ± 1.4 and 2.3 ± 1.2 time/week, respectively. At the end of the study, the mean CSBM weekly increased in the lactulose group (mean difference 1.3 ± 1.6, P < 0.001) and the senna plus ispaghula husk group (mean difference 2.1 ± 2.1, P < 0.001) from baseline. Comparing CSBM between lactulose and senna plus ispaghula husk exhibited no significant difference (95% CI -1.2 to 0.06; P = 0.276). BSFS was significantly changed after using ispaghula husk with senna, the mean ± SD of BSFS changed to 1.7 ± 1.8 (p = 0.001) and after use lactulose, the mean ± SD of BSFS changed to 1.6 ± 1.8 (p = 0.001). No significant BSFS change was observed between groups regarding stool appearance. No serious adverse event in either group was found. CONCLUSION: Lactulose and senna plus ispaghula husk were similar in efficacy to treat constipation among patients with pre-dialysis CKD. TRIAL REGISTRATION: Thai Clinical Trials number is TCTR20200818006. Retrospectively Registered 18 August 2020.

Efficacy of Weekly Split versus Single Doses of Ergocalciferol on Serum 25-Hydroxyvitamin D among Patients on Continuous Ambulatory Peritoneal Dialysis: A Randomized Controlled Trial.

BACKGROUND: Vitamin D deficiency is a common problem among patients on continuous ambulatory peritoneal dialysis (CAPD). Vitamin D supplementation leads to reduced serum parathyroid hormone levels and improved cardiovascular markers. Different doses and time intervals of oral vitamin D supplementation may differ in each patient on dialysis. The study aimed to evaluate the efficacy of weekly split and single dose of ergocalciferol at 60,000 IU on serum 25-hydroxyvitamin D (25(OH)D) among patients on CAPD. METHODS: A randomized study was conducted among patients on CAPD with vitamin D deficiency or insufficiency (25(OH)D < 30 ng/mL). Patients were randomly assigned to two groups: the split dose group was given ergocalciferol 20,000 IU three times weekly and the single dose group was given ergocalciferol 60,000 IU once weekly for 8 weeks. Main outcomes measured serum 25(OH)D concentrations, serum calcium, serum phosphate, and intact parathyroid levels at 8 weeks after being enrolled. RESULTS: Of 128 screened patients, 50 met the criteria for eligibility and were randomized. At 8 weeks after treatment, mean serum 25(OH)D concentrations significantly increased from baseline 22.7 ± 5.9 to 29.5 ± 9.5 ng/mL (P=0.004) in the split dose group and 22.9 ± 5.3 to 31.2 ± 12.3 ng/mL (P=0.003) in the single dose group. No significant change was found in increase of serum 25(OH)D between the two groups (P=0.561). At the end of study, a similar proportion of patients in both groups reached the desirable serum concentration of 25(OH)D ≥ 30 ng/mL (60% in the single group vs. 40% in the split group, P=0.258). No significant cases of hypercalcemia, hyperphosphatemia, or serious adverse events occurred during the study. CONCLUSION: Weekly single and split doses of ergocalciferol 60,000 IU achieved similar effects on serum 25(OH)D levels among patients on CAPD with vitamin D insufficiency or deficiency, suggesting that weekly single dose would be prescribed for adequate vitamin D repletion. This trial is registered with TCTR20200821005.

Impaired Glomerular Filtration Rate in Type 2 Diabetes Mellitus Subjects: A Nationwide Cross-Sectional Study in Thailand.

BACKGROUND: Type 2 diabetic mellitus (T2DM) patients with impaired renal function have a higher risk of mortality, and often progress to end-stage renal disease. The study aims to determine the prevalence of kidney disease and investigate the relationship between various factors and impaired renal function in a large population of patients with T2DM. METHODS: We conducted a cross-sectional study among 30,377 patients from a nationwide diabetes study involving 602 Thai hospitals. Impaired glomerular filtration rate (GFR) was defined as <60 mL/min per 1.73 m2. Multivariate logistic regression was used to determine the association between standard risk factors and impaired GFR. RESULTS: The prevalence of impaired GFR in a T2DM population was 39.2%. After adjusting for multiple risk factors, advanced age (adjusted OR 11.69 (95%CI = 3.13 to 43.61)), macroalbuminuria (adjusted OR 3.54 (95%CI = 1.50 to 8.40)), high serum uric acid (adjusted OR 2.06 (95%CI = 1.73 to 2.46)), systolic BP 130-139 mmHg (adjusted OR 3.21 (95%CI = 1.30 to 7.96)), hemoglobinA1C (HA1C) <6% (adjusted OR 3.71 (95%CI = 1.65 to 8.32)), and HA1C >7% (adjusted OR 2.53 (95%CI = 1.38 to 4.63)) were found to be associated with a significantly increased risk of impaired GFR among T2DM patients. CONCLUSION: Almost 40% of patients with T2DM in a nationwide cross-sectional study in Thailand had impaired GFR. Advanced age, albuminuria, hyperuricemia, hypertension, HA1C <6%, and HA1C >7% were independently associated with increased prevalence of impaired GFR.

Urinary biomarkers of tubular injury to predict renal progression and end stage renal disease in type 2 diabetes mellitus with advanced nephropathy: A prospective cohort study.

BACKGROUND: Novel potential tubular biomarkers in diabetic nephropathy could improve risk stratification and prediction. The study aimed to evaluate the association of tubular damage markers with rapid renal progression and incidence of end stage renal disease (ESRD) in type 2 diabetes (T2DM). METHODS: A prospective cohort study, involving a total of 257 patients with T2DM, was included. The baseline values of urine albumin, cystatin-C, angiotensinogen, kidney injury molecule-1 (KIM-1) and neutrophil-gelatinase associated lipocalin (NGAL) were measured. The composite outcomes included a rapid glomerular filtration rate (GFR) decline or incident of ESRD at 3-year follow-up. MAIN FINDINGS: The composite outcomes were noted in 26.1%. Using univariate followed by multivariate COX proportional hazard regression analysis, the patients with highest quartiles of urine cystatin-C (HR 2.96, 95% CI, 1.38-6.35), urine angiotensinogen (HR 2.93, 95% CI, 1.40- 6.13) urine KIM-1 (HR 2.77, 95% CI, 1.27-6.05) and urine NGAL (HR 2.53, 95% CI, 1.11-5.76) were significantly associated with rapid renal progression when compared with the patients with the lowest quartiles of all tubular biomarkers. CONCLUSIONS: Patients with T2DM with high levels of baseline urine tubular biomarkers (cystatin-C, angiotensinogen, KIM-1 and NGAL) had a greater incidence of ESRD and rapid GFR decline.

Prevalence and associated factors of uncontrolled blood pressure among hypertensive patients in the rural communities in the central areas in Thailand: A cross-sectional study.

INTRODUCTION: Hypertension is a common cardiovascular disease at present. Uncontrolled blood pressure leads to further complications including heart attack, stroke and chronic kidney disease. In Thailand, most of the information related to this issue is collected by hospitals or hospital-based organizations rather than at the community level. The objectives of this study were to determine the prevalence of uncontrolled hypertension and to assess the relationship between patient characteristics (socio-behavioral and clinical) and uncontrolled blood pressure among hypertensive patients in the rural communities in the central areas in Thailand. MATERIALS AND METHODS: This was a cross-sectional study conducted in Na-Yao and Phra-Pleong rural communities of Thailand in 2018 using the total design method. In all, 406 individuals aged ≥18 years were interviewed using structured questionnaires related to demographic information, higher risk behavior, comorbidities and arthrometric measurement. Blood pressure was assessed for all participants. Uncontrolled hypertension was defined as BP ≥140/90 mmHg. RESULTS: The prevalence of uncontrolled hypertension was 54.4% (males: 59.8%; females: 52.4%). Uncontrolled blood pressure was associated with neck circumference more than 35.75 cm for males and 32.75 cm. for females (adjusted odds ratio; 1.66, 95% confidence interval; 1.03-2.68), sedentary behavior more than 5 hours a day (adjusted odds ratio; 2.03, 95% confidence interval; 1.28-3.23) and missed doctor appointments (adjusted odds ratio; 3.29, 95% confidence interval; 1.09-9.94). CONCLUSION: Approximately one half of hypertensive patients in these rural communities had uncontrolled blood pressure. The Ministry of Public Health and health care providers should provide further strategies to prevent uncontrolled blood pressure's complications.

Obesity and its relation to chronic kidney disease: a population-based, cross-sectional study of a Thai army population and relatives.

AIM: Obesity represents a significant problem in patients with cardiovascular disease and chronic kidney disease (CKD). The aim of the present study was to investigate the association between body mass index (BMI) and CKD in Thai individuals. METHODS: Participants underwent general health screening. Overweight, weight at risk, obese I and obese II were defined as having a BMI ≥23 kg/m(2), 23-24.9 kg/m(2) , 25-29.9 kg/m(2) and ≥30 kg/m(2), respectively. Waist circumference ≥ 90 cm for men and > 80 cm for women were represented by abdominal obesity. CKD was defined as a glomerular filtration rate (GFR) < 60 mL/min per 1.73 m(2). An estimate of the GFR was obtained by the four-variable Modification of Diet in Renal Disease (MDRD) equation. RESULTS: The study population had 12 348 males and 3009 females. The survey population had a 7.5% prevalence of CKD. There was also a significant graded relationship between the degrees of overweight with the prevalence of CKD. Mean BMI were 25.36 ± 3.29 kg/m(2) for CKD subjects and 24.04 ± 3.13 kg/m(2) for non-CKD subjects (P < 0.001). Prevalence of overweight and abdominal obesity in the participants with CKD were found to be higher than in those without CKD (overweight, 77.6% vs. 61.6%, P < 0.001; abdominal obesity, 35.7% vs. 25.3%, P < 0.001). In a multivariate logistic regression analysis, weight at risk (adjusted odds ratio 1.29; 95% CI 1.07-1.54), obese I (adjusted odds ratio 1.58; 95% CI 1.33-1.87) and obese II (adjusted odds ratio 1.65; 95% CI 1.24-2.19) were associated with CKD. CONCLUSION: Our data showed that overweight and obesity were associated with CKD in Thai members of the army population and their relatives undergoing a general health screening, independently of age, gender, blood pressure, serum lipid, uric acid and glucose levels.

Kidney failure requiring kidney transplantation after pancreas transplant alone.

Pancreas transplant alone (PTA) is usually performed in type 1 diabetic patients with preserved renal function to correct severe metabolic complications. One of the major concerns is renal failure after PTA. Here, we reported the cumulative incidence of kidney failure requiring kidney transplantation (KF/KT) among PTA recipients in the United States. Using the Organ Procurement Transplant Network/ United Network for Organ Sharing database, all primary adult PTA recipients with estimated baseline glomerular filtration rate (by the Modification of Diet in Renal Disease equation) >or=60 mL/min/1.73m2 were selected (n=1085). KF/ KT after PTA was defined as: wait-listing for or receiving a kidney alone (KA) or simultaneous pancreas kidney (SPK) transplant. The median follow-up time was 1185 days (25-75%: 524-2183). Ten years post PTA, 120 (11.1%) patients developed KF/KT; of those, 70 (6.5%) subsequently received a KA/SPK transplant (56 received KA and 14 received SPK) and 50 (4.6%) recipients were listed without receiving a transplant. The cumulative incidence of KF/KT after PTA at 1, 3, and 5 years after PTA was 0.3, 2.5, and 9.7%, respectively. In conclusion, KF/KT after PTA was not uncommon (9.7% at 5 years), and prospective PTA recipients should be aware of the risks of kidney failure after transplantation.

Zero-mismatch deceased-donor kidney versus simultaneous pancreas-kidney transplantation.

BACKGROUND: Patients with type 1 diabetes mellitus (T1DM) and end-stage renal disease may receive a simultaneous pancreas-kidney (SPK), living-donor kidney (LDK), or deceased-donor kidney (DDK) with possible pancreas after kidney transplantation. SPK is associated with superior patient and kidney graft survival compared with DDK, whereas SPK and LDK have comparable outcomes. It is unclear whether SPK and LDK offer a survival benefit over zero-mismatch (0MM) DDK. In this study, we compared the outcomes of T1DM recipients using data from the Organ Procurement and Transplant Network/United Network for Organ Sharing. METHODS: Adult (≥18 years) first-time transplant recipients with T1DM waitlisted for SPK and transplanted from 1995 to 2010 were included in this study. Patient and death-censored kidney graft survival were compared between 0MMDDK (n=228), mismatched (MM) DDK (n=964), 0MMSPK (n=215), MMSPK (n=11951), 2 haplotype identical (2hap) LDK (n=205), and non-2hapLDK (n=1719) recipients. Multivariate analysis was performed using stepwise Cox proportional hazards models. RESULTS: At 7 years, patient and death-censored graft survival of 0MMDDK recipients (85% and 81%, respectively) were not statistically different from that of 0MMSPK (81% and 85%; log-rank P value vs. 0MMDDK, 0.17 and 0.48, respectively) and 2hapLDK recipients (89% and 86%; log-rank P value vs. 0MMDDK, 0.34 and 0.18, respectively). Among all groups, MMDDK showed the worst patient survival (71%; log-rank P value vs. 0MMDDK, 0.001) CONCLUSION: Patient and kidney graft survival of 0MMDDK recipients were comparable to both SPK and LDK recipients. These findings suggest that T1DM patients awaiting SPK may consider accepting a 0MMDDK if an offer is available.

A single-centre experience: peritoneal dialysis-related infections in patients on long-term dialysis.

OBJECTIVE: Peritoneal dialysis is a convenient way of maintaining patients with end stage renal disease (ESRD) and in the present days, the Thai government supports all payments for ESRD patients. Continuous ambulatory peritoneal dialysis-(CAPD) related infections are the major cause of morbidity and mortality. The present study was conducted to identify the incidence and epidemiological data of CAPD-related infection. MATERIAL AND METHOD: Medical records of 333 CAPD patients attending the Dialysis Unit of Phramongkutklao Hospital from January 1983 to June 2007 were reviewed. The historical cohort study was focused on the incidence of CAPD-related infections, causing pathogens, risk factors, and patient outcome. RESULTS: In total, 73.3% of episodes developed peritoneal infection. The incidences of peritonitis, exit site infection, and tunnel infection were 0.864, 0.213, and 0.034 episodes per patient per year, respectively. The most common infecting organisms were gram positive cocci (49.1%). The main pathogens were Coagulase-negative staphylococcus (15.9%), Staphylococcus aureus (15.2%) and Pseudomonas spp. (14.2%). CAPD-related infections increased in patients who had age > 60. A total of 81% of the infections responded to initial antibiotic therapy administered in the dialysis fluid. Overall, there were 10 episodes (1.9%) of the refractory group and 83 episodes (15.4%) of peritoneal catheter loss, with an overall mortality rate of 1.1%. Non-vancomycin based regimens were applied in 63.9% of peritoneal infected patients. CONCLUSION: The authors' center's CAPD-related infection rate achieved the International Society for Peritoneal Dialysis (ISPD) recommendation. A significantly enhanced incidence of CAPD-related infection occurred in advanced age. Coagulase-negative staphylococcus is still a very common organism that generally responds well to antibiotic therapy.

Insulin resistance in dialysis versus non dialysis end stage renal disease patients without diabetes.

OBJECTIVE: Insulin resistance is frequently recognized in uremic patients and is a predictor of cardiovascular mortality in end stage renal disease (ESRD) patients. However sparse data are available regarding the effects of different methods of renal dialysis on insulin resistance in ESRD without diabetes. The present study was conducted to evaluate the levels of insulin resistance in dialysis versus non dialysis ESRD patients without diabetes. MATERIAL AND METHOD: A cross-sectional study was carried out in 45 non diabetic ESRD patients including continuous ambulatory peritoneal dialysis (CAPD), hemodialysis (HD), and non dialysis ESRD patients. The value of insulin resistance was obtained by homeostasis model assessment (HOMA). Estimation of the glomerular filtration rate (GFR) was obtained by the four-variable Modification of Diet in Renal Disease equation and ESRD was defined when GFR was below 15 ml/min/1.73 m2. RESULTS: Non diabetic ESRD patients were studied: 12 patients on CAPD treatment for 67.4 months, 18 patients on HD treatment for 89.3 months, and 15 patients on conservative treatment. HOMA scores (CAPD 5.4 +/- 2.3, HD 6.0 +/- 1.9 vs. non dialysis 1.5 +/- 0.9, p < 0.05) and fasting plasma insulin levels (CAPD 21.9 +/- 7.7 microU/mL, HD 19.5 +/- 8.4 microU/mL vs. non dialysis 4.4 +/- 2.5 microU/mL, p < 0.05) of the CAPD and HD groups were significantly higher than the non dialysis ESRD group, with no significant differences observed between CAPD and HD groups. However, fasting plasma glucose was significantly lower in the HD group than the CAPD and non dialysis ESRD groups (CAPD 98.2 +/- 10.6 mg/dL, non dialysis 93.0 +/- 11.5 mg/dL vs. HD 76.2 +/- 7.8 mg/dL, p < 0.05). All groups showed no significant differences for blood pressure, body weight, body mass index, fat free mass, body fat, and serum levels of albumin, total cholesterol, LDL-cholesterol, HDL-cholesterol, and triglycerides. CONCLUSION: Impaired insulin sensitivity in both dialysis groups after long term dialysis was still higher than that of the non dialysis ESRD group. However, no significant differences were noted between CAPD and HD treatments.

High levels of uric acid correlate with decline of glomerular filtration rate in chronic kidney disease.

BACKGROUND: Clinical studies have suggested that high levels of uric acid may contribute to the development of hypertension and kidney disease. However the relation between uric acid and chronic kidney disease (CKD) has been inconsistent. OBJECTIVE: To examine the association between plasma concentration of uric acid, and estimated glomerular filtration rate (GFR) in CKD subjects. MATERIAL AND METHOD: In a cross-sectional study, authors surveyed 5,558 subjects, but only 750 CKD subjects in whom GFR was between 15 and 60 ml/min/1.73 m2 were included in the study. The GFR values were calculated by Cockcroft-Gault formula. RESULTS: There were 65.5% males, mean age of 50.29 +/- 6.39 years and body mass index (BMI) of 21.68 +/- 2.64 kg/m2. The mean value of estimated GFR was 53.86 +/- 6.29 ml/min/1.73 m2. In subjects with serum uric acid fourth quartile displayed significantly higher BMI, higher systolic blood pressure (BP), higher diastolic BP, higher BUN, and higher serum creatinine, and lower estimated GFR as compared with the three lower quartiles. The correlation analysis showed that estimated GFR was negatively correlated with serum uric acid (r = -0.208, p < 0.01), age (r = -0.171, p < 0.01), systolic BP (r = -0.148, p < 0.01) and BMI (r = -0.147, p < 0.01). Multiple regression analysis, the presence of high serum uric acid levels were independently associated with a decline of GFR. CONCLUSION: In CKD subjects, high levels of uric acid were independent associated with GFR decline. Our finding suggests that early detection and prevention on hyperuricemia in CKD subjects are critical.