Evaluation of the Impact of a New Synthetic Vitamin E-Bonded Membrane on the Hypo-Responsiveness to the Erythropoietin Therapy in Hemodialysis Patients: A Multicenter Study.

BACKGROUND: Oxidative stress has been related to hypo-response to erythropoiesis-stimulating agents (ESAs) in hemodialysis (HD) patients. The aim of this study was to verify whether vitamin E (ViE) on a synthetic polysulfone dialyzer can improve ESA responsiveness. METHODS: This controlled, multicenter study involved 93 HD patients on stable ESA therapy, who were randomized to either ViE-coated polysulfone dialyzer or to a low-flux synthetic dialyzer. The primary outcome measure was the change in ESA resistance index (ERI) from baseline. RESULTS: Mean ERI decreased in the ViE group by 1.45 IU/kg*g/dl and increased in the control group by 0.53 IU/kg*g/dl, with a mean difference of 1.98 IU/kg*g/dl (p = 0.001 after adjusting for baseline ERI, as foreseen by the study protocol). Baseline ERI was inversely related to its changes during follow-up only in the control group (R2 = 0.29). CONCLUSIONS: The ViE dialyzer can improve ESA response in HD patients. Changes in ERI during follow-up are independent from baseline ERI only in the ViE group. Video Journal Club 'Cappuccino with Claudio Ronco' at http://www.karger.com/?doi=453442.

Lessons from recent trials on hemodialysis.

Today, hemodialysis (HD) represents a rescue therapy for an increasing number of patients worldwide. Thanks to continuous improvements, it is now better tolerated; thus, allowing patients relief from uremic symptoms and increasing survival. However, many questions regarding the best way of ameliorating the outcomes of chronic kidney disease patients requiring dialysis are still open. Recently, 2 randomized controlled clinical trials tried to give some answers to the current debates around dialysis. The first one--the IDEAL trial--evaluated the effects of beginning early or late dialysis on patient mortality and morbidity, and it did not find any significant difference between the 2 groups, suggesting that starting dialysis on the basis of an estimate of GFR alone is not suitable. The second one--the FHN daily trial--compared in-center conventional (3 times per week) with in-center frequent (6 times per week) HD. It found that daily dialysis is associated with improvements in left ventricular mass, physical health composite scores and some secondary outcomes (hypertension and hyperphosphatemia) - although it also discovered there had been more frequent interventions related to vascular access. Despite the fact that both studies presented some unavoidable limitations, they gave important information which is useful in everyday clinical practice. According to evidence-based medicine, such well-designed and well-conducted randomized controlled trials are the best way to improve our knowledge.

Subclinical impairment of coronary flow velocity reserve assessed by transthoracic echocardiography in young renal transplant recipients.

BACKGROUND: In renal transplant recipients (RTR) an increased risk to develop cardiovascular injury is present. Transthoracic Doppler echocardiographic assessment of coronary flow velocity reserve (CFVR), a sensitive and minimally invasive technique, was recently employed to detect both macrovascular and microvascular coronary artery disease (CAD) in different clinical settings. The prevalence of coronary involvement in young adult RTR is still unknown. The aim of the study was to investigate the presence of early cardiovascular damage in asymptomatic young adult RTR. METHODS: Transthoracic Doppler echocardiographic-derived CFVR and common carotid intima-media thickness (IMT) were assessed in 25 asymptomatic young adult RTR (mean age 25.7+/-7.0 years; range 17.3-43.9) without CAD and 25 healthy controls. RESULTS: CFVR was lower in young adult RTR compared to controls (2.8+/-0.6 vs. 3.5+/-0.8; P<0.001), meanwhile left ventricular wall motion and common carotid IMT were comparable in both groups. We found a negative correlation between CFVR and age (r=-0.50; P=0.018) and months on dialysis (r=-0.54; P<0.01). CONCLUSIONS: Young adult RTR showed a reduced CFVR reflecting an impaired coronary microcirculation, which is significantly related to the age and duration of dialysis; coronary microvascular damage is detectable in the absence of changes in common carotid IMT. Non-invasive evaluation of CFVR by transthoracic stress echocardiography could be a reliable method for identification of early coronary microvascular involvement in young adult RTR.

Reduced coronary flow reserve in young adults with renal transplant.

BACKGROUND: Some degree of cardiovascular disease should be suspected in young adults who have been paediatric renal transplant recipients also if no systematic data collection is routinely performed in clinical setting. The aim of our work was to evaluate the degree of cardiovascular damage in these young patients, using a minimally invasive technique. We then evaluated coronary flow reserve (CFR) and carotid intima-media thickness (IMT) in 25 patients (13 males, median age 23.7 years). METHODS: Coronary flow velocity on the left anterior descending coronary artery was assessed by transthoracic echocardiography, before and after dipyridamole, after standard echocardiography. CFR was compared with that of a small control group (n = 16; median age 25 yrs). RESULTS: In this relatively young sample, mean CFR was 2.8 +/- 0.6 (median 2.75), and half of the patients had reduced coronary reserve (P = 0.01). Mean IMT (0.48 +/- 0.08 mm) was only slightly, though significantly larger compared with the reference standard (P < 0.05) but was significantly thinner in normotensive than in hypertensive patients (0.42 +/- 0.06 vs 0.49 +/- 0.05 mm, P < 0.05). The time on dialysis prior to transplantation, hypertension and age at the time of CFR evaluation affect CFR. IMT did not correlate with CFR. CONCLUSIONS: CFR and IMT abnormalities are common in young transplant recipients, in spite of the fact that our paediatric population has much less of the atherosclerotic 'legacy' common to adult patients.

Successful medical treatment of multiple brain abscesses due to Nocardia farcinica in a paediatric renal transplant recipient.

Brain abscesses caused by Nocardia are rare, but it is very important to detect and treat them early because the associated mortality is 3 times higher than that associated with other bacterial brain abscesses. This infection is prevalent among adults on long-term immunosuppressive therapy; we report the case of a male kidney transplant recipient aged 12.7 years who developed early multiple Nocardia-induced brain abscesses that were successfully treated with linezolid, a novel antibiotic therapy.