Increased renal resistive index in type 2 diabetes: Clinical relevance, mechanisms and future directions.

Type 2 diabetes is a global health challenge. In type 2 diabetes both microvascular (nephropathy, retinopathy, neuropathy) and macrovascular complications arise. In kidney, renal pathological changes leading to diabetic nephropathy are mainly secondary to atherosclerosis of the intra and extra renal arteries together with microangiopathy of the glomerular capillaries, afferent arterioles and efferent arterioles. Renal resistive index (RRI) is defined as a ratio of the difference between maximum and minimum (end-diastolic) flow velocity to maximum flow velocity derived from the Doppler measurements of main renal and intrarenal (segmental/interlobar) arteries. Renal resistive index is tightly related to renal arteriolosclerosis, and represents an integrated index of arterial compliance, pulsatility and downstream microvascular impedance. In meantime, growing suggest that RRI has also been closely related with atherosclerosis. Most studies performed in type 2 diabetes showed RRI is increased in type 2 diabetes. In this review, we summarize the data regarding RRI with regard to performed studies, pathogenesis and prognosis, especially focusing on type 2 diabetes (T2D). We also review the data regarding the development of metabolic syndrome (MetS) and RRI.

The relationship between weight, height and body mass index with hemodynamic parameters is not same in patients with and without chronic kidney disease.

BACKGROUND: Although anthropometric measurements are related with clinical outcomes; these relationships are not universal and differ in some disease states such as in chronic kidney disease (CKD). The current study was aimed to analyze the relationship between height, weight and BMI with hemodynamic and arterial stiffness parameters both in normal and CKD patients separately. METHODS: This cross-sectional study included 381 patients with (N 226) and without CKD (N 155) with hypertension. Routine laboratory and 24-h urine collection were performed. Augmentation index (Aix) which is the ratio of augmentation pressure to pulse pressure was calculated from the blood pressure waveform after adjusted heart rate at 75 [Aix@75 (%)]. Pulse wave velocity (PWV) is a simple measure of the time taken by the pressure wave to travel over a specific distance. Both [Aix@75 (%)] and PWV which are measures of arterial stiffness were measured by validated oscillometric methods using mobil-O-Graph device. RESULTS: In patients without CKD, height is inversely correlated with [Aix@75 (%)]. Additionally, weight and BMI were positively associated with PWV in multivariate analysis. However, in patients with CKD, weight and BMI were inversely and independently related with PWV. In CKD patients, as weight and BMI increased stiffness parameters such as Aix@75 (%) and PWV decreased. While BMI and weight are positively associated with arterial stiffness in normal patients, this association is negative in patients with CKD. CONCLUSION: In conclusion, height, weight and BMI relationship with hemodynamic and arterial stiffness parameters differs in patients with and without CKD.

Central hemodynamics, vascular stiffness, and nocturia in patients with type 2 diabetes.

Recently, studies have shown that the presence of nocturia may not be a benign condition and related with systemic illness and mortality. Elevated blood pressure (BP) was another factor related with nocturia. Type 2 diabetes mellitus (T2DM) is also associated with nocturia. It is now clear that, apart from peripheral BP, central hemodynamic parameters are important for cardiovascular prognosis. However, no previous study in the literature examined the relationship between nocturia and central hemodynamic parameters in patients with T2DM. The current study was designed to examine these relationships. Nocturia was defined as two or more voids per night. Central hemodynamic parameters were assessed from ambulatory BP measurements. In addition to routine biochemistry, 24-h urine collection was performed to measure protein, albumin, and sodium excretion. 158 patients (52.3%) had T2DM and 144 (47.7%) did not have T2DM (control group). The presence of T2DM was independently related with nocturia. Both in whole group and in T2DM patients, most of the hemodynamic parameters are higher in patients with nocturia compared to patients without nocturia. Among patients with T2DM, nocturia was associated with augmentation index and pulse wave velocity. In conclusion, central hemodynamic parameters and markers of vascular stiffness may be related with nocturia in patients with T2DM.

Association between serum bicarbonate and pH with depression, cognition and sleep quality in hemodialysis patients.

Metabolic acidosis is a common feature in chronic renal failure patients, worsening progressively as renal function declines. There are conflicting data in hemodialysis (HD) patients with regard to acidosis, alkalosis and mortality. In HD patients, cognitive impairment, depression, sleep disorders and impaired quality of life are very common. Besides, these conditions are related with increased morbidity and mortality. However, no previous study investigated the relationship between pH, venous bicarbonate and anion gap with depression, sleep problems and cognitive function in HD patients. In this study we investigated these relationships. In total, 65 HD patients were included. The demographic parameters and laboratory parameters including bicarbonate, pH and anion gap was measured for all patients. Depressive symptoms, sleep quality and cognitive function, were measured by Beck depression inventory, The Pittsburgh Sleep Quality Index and by Mini Mental State Examination, respectively. We found that, sleep quality but not cognitive function or depression was independently related with venous pH and bicarbonate. Anion gap has no independent relationship with sleep quality, cognitive function and depression. In conclusion, metabolic acidosis and bicarbonate levels were independently related with sleep quality in HD patients. However, there was no association between metabolic acidosis and bicarbonate levels with cognitive function and depression.

Urinary sodium excretion and ambulatory blood pressure findings in patients with hypertension.

Use of ambulatory blood pressure (BP) monitoring (ABPM) allows for identification of dipping, nondipping, extreme dipping, and reverse dipping of BP. Using office BP and ABPM, hypertension subtypes can be identified: sustained normotension (SNT), white-coat hypertension, masked hypertension, and sustained hypertension. The comparison of hemodynamic parameters and salt intake has not been investigated among these patient groups. Office BP, ABPM, augmentation index (AIx), pulse wave velocity (PWV), cardiac output (CO), and total peripheral resistance (TPR) were automatically measured. Estimation of salt intake was assessed by 24-hour urinary sodium excretion. Urinary sodium excretion was not different among groups. AIx, PWV, CO, and TPR were lowest in patients with SNT. CO was lowest while AIx adjusted for a heart rate of 75 beats per minute, PWV, and TPR were highest in the extreme dipper group. No relationship was detected between hypertension subtypes and urinary sodium excretion.

Serum uric acid and arterial stiffness in hypertensive chronic kidney disease patients: sex-specific variations.

OBJECTIVE: Hyperuricemia and arterial stiffness are associated with increased cardiovascular risk. The specific relationship between arterial stiffness and serum uric acid (SUA) in chronic kidney disease (CKD) patients has not been investigated. We investigated whether the SUA level is associated with arterial stiffness in hypertensive CKD patients. MATERIALS AND METHODS: This study had a single-center, cross-sectional design. A total of 339 hypertensive CKD patients (female/male=192/147, mean age 57.9±13.9 years) were recruited. Arterial stiffness was assessed by pulse wave velocity (PWV) and augmentation index adjusted for heart rate (AIx@75). RESULTS: SUA was correlated negatively with night-time wave reflection magnitude (P=0.015), 24-h AIx@75 (P<0.0001), daytime AIx@75 (P<0.0001), and night-time AIx@75 (P=0.014), and was correlated positively with 24-h PWV (P<0.0001), daytime PWV (P<0.0001), and night-time PWV (P<0.0001). SUA was correlated negatively with 24-h AIx@75 (P=0.024), daytime AIx@75 (P=0.023), and night-time AIx@75 (P=0.047) in men, whereas SUA was correlated positively with 24-h PWV (P<0.0001), daytime PWV (P<0.0001), and night-time PWV (P<0.0001) in women. In adjusted analysis, SUA was associated independently with AIx@75, but not with PWV. In sex-specific unadjusted analysis, SUA was associated significantly with PWV only in women, which lost significance in adjusted analysis. SUA was associated significantly with AIx@75 only in men, which remained significant after adjustment for confounders. CONCLUSION: In hypertensive CKD patients, SUA was correlated with the two indices of arterial stiffness, PWV and AIx@75, with sex-specific variations. However, SUA was associated independently with only AIx@75, but not with PWV, in the entire patient population and only in men.

Free triiodothyronine in hemodialysis patients: link with malnutrition and inflammation.

INTRODUCTION: Free triiodothyronine (FT3) is a marker of comorbidity in end-stage renal disease and in many acute and chronic diseases. There is lack of data about the link between FT3 levels and malnutrition and inflammation in hemodialysis patients. The objective of the present study was to investigate the link between FT3 and malnutrition and inflammation in hemodialysis patients. MATERIALS AND METHODS: A total of 84 patients were included in the study (38 men and 46 women; mean age, 56.2 +/- 14.8 years; hemodialysis duration, 95.72 +/- 10.35 months). Serum FT3, free thyroxin, and thyroid-stimulating hormone concentrations were determined. Demographic data and laboratory values were evaluated. Patients' comorbidity status was determined using the Charlson Comorbidity Index (CCI), and malnutrition-inflammation status was determined by Malnutrition-Inflammation Score (MIS). RESULTS: Serum FT3 concentration inversely correlated with age (r = -0.328, P = .002), CCI (r = -0.591, P = .001), C-reactive protein (r = -0.299, P = .01), and MIS (r = -0.671, P = .001), and positively correlated with serum albumin (r = 0.389, P = .001). In multivariate linear regression analysis, FT3 was independently associated with MIS (beta;, -0.14; 95% confidence interval, -0.175 to 0.063, P = .003), adjusted for CCI, C-reactive protein level, serum albumin level, and MIS. CONCLUSIONS: The results of this study indicate that FT3 is negatively correlated with inflammatory markers, namely C-reactive protein, and it is independently related with MIS in hemodialysis patients. Therefore, we suggest that FT3 can be accepted as an inflammatory marker in hemodialysis patients.

The relationship between central hemodynamics, morning blood pressure surge, glycemic control and sodium intake in patients with type 2 diabetes and essential hypertension.

AIMS: The current study aimed to investigate the relationship between morning blood pressure surge (MBPS), hemodynamic parameters, glycemic control and 24-h urinary sodium excretion (USE) in patients with type 2 diabetes mellitus (T2DM). MATERIALS AND METHODS: MBPS and central hemodynamic parameters were assessed from ambulatory blood pressure measurements. In addition to routine biochemistry, 24h urine collection was performed to measure protein, albumin and sodium excretion. RESULTS: There were 146 (38%) patients with T2DM and 238 (72%) patients without T2DM (control group). Patients with T2DM had statistically higher MBPS compared with patients without T2DM (P<0.0001). In patients with T2DM, MBPS was correlated with HbA1c (rho=0.311, P<0.0001), 24h urinary sodium excretion (USE) (rho=0.292, P=0.004) and various hemodynamic parameters. Additionally, regression analysis showed that being male (P=0.006), the presence of coronary artery disease (P=0.023), HbA1c (P=0.012), and 24h USE (P=0.001) were independently related with log MBPS in T2DM patients. CONCLUSION: This study demonstrated that T2DM was an independent risk factor for increased MBPS and MBPS was associated with central hemodynamic parameters. Additionally poor glycemic control and sodium intake were associated with worse MBPS in T2DM.

The relationship between magnesium and ambulatory blood pressure, augmentation index, pulse wave velocity, total peripheral resistance, and cardiac output in essential hypertensive patients.

Magnesium levels have been shown to be associated with elevated blood pressure (BP), endothelial dysfunction, insulin resistance, vascular calcification, inflammation, and atherosclerosis. It was also demonstrated that patients with hypertension have increased inflammation, insulin resistance, and endothelial dysfunction. However, the relationship between magnesium, ambulatory BPs, and central hemodynamic parameters were not evaluated extensively. Serum magnesium levels, ambulatory blood pressures, augmentation index (Aix), pulse wave velocity, total peripheral resistances, and cardiac output were measured for all patients. In total, 184 essential hypertension patients were enrolled. In univariate analysis, magnesium levels were correlated with hemoglobin (r = +0.155; P = .037), albumin (r = +0.180; P = .018), pulse pressure (daytime; r = -0.170; P = .021), pulse pressure (24-hour; r = -0.156; P = .035), Aix (daytime; r = -0.223; P = .002), Aix (nighttime; r = -0.169; P = .022), and Aix (24-hour; r = -0.247; P = .001). In regression analysis, magnesium levels were independently and conversely associated with daytime Aix (P < .0001), nighttime Aix (P = .019), and 24-hour Aix (P < .0001). We suggest that magnesium levels were associated with Aix but not with total peripheral resistances, pulse wave velocity, cardiac output, and central BPs. The unique mechanisms related with magnesium and Aix but not shared by other central parameters needs to be determined.

Basal renal function reserve and mean kidney dose predict future radiation-induced kidney injury in stomach cancer patients.

BACKGROUND: Adjuvant chemoradiotherapy (CRT) improves the survival in patients with locally advanced stomach cancer. The kidneys are the major dose-limiting organs for radiotherapy (RT) in upper abdominal cancers. We aimed to evaluate the impact of adjuvant CRT on renal function of patients with stomach cancer. MATERIAL AND METHODS: Fifty-nine stomach cancer patients who underwent postoperative CRT were included. Demographic parameters (age, gender), and basal and 12th-month biochemical parameters were recorded. Mean kidney dose (MKD) administered was determined. Estimated glomerular filtration rate (eGFR) was calculated by modification of diet in renal disease formula. RESULTS: Fifty-nine patients were recruited (age 60.8 ± 11.9 years; female/male 25/34; follow-up duration 15.6 ± 9.8 months). Twenty-one patients (35.6 %) had basal eGFR <90 ml/min/1.73 m(2). When the basal and 12th-month eGFR was compared, eGFR decreased in 27 patients (45.8 %), whereas eGFR remained stable in 32 (54.2 %) patients. Cox regression analyses revealed that a MKD ≥1,500 cGy and basal eGFR <90 ml/min/1.73 m(2) significantly increased the risk of a decreased eGFR at 12th month (HR = 2.288, 95 % CI 1.009-5.188, p = 0.048 and HR = 2.854, 95 % CI 1.121-7.262, p = 0.028, respectively). CONCLUSION: MKD ≥1,500 cGy and a basal eGFR <90 ml/min/1.73 m(2) significantly increased the risk of a decreased eGFR at 12th month. We suggest that patients with stomach cancer be evaluated for their basal renal reserve prior to RT, and it may be more convenient to further minimize the dose to the kidneys with more sophisticated RT techniques in patients with stomach cancer, more specifically in patients with decreased renal reserve.

Body shape index and mortality in hemodialysis patients.

OBJECTIVE: The relationship between various anthropometric parameters and mortality in hemodialysis (HD) patients is conflicting. Recently a new anthropometric parameter emerged, namely, body shape index (BSI). BSI is based on waist circumference (WC) but is independent of height, weight, and body mass index in predicting mortality in the general population. The aim of this study was to determine the relationship between BSI and mortality in HD patients. METHODS: This retrospective study evaluated the demographic characteristics and anthropometric measures including BSI, laboratory parameters, and mortality data in HD patients in a single center. RESULTS: There were 142 HD patients enrolled in the study. The median BSI was 0.0816. Because no normal value was defined for BSI, the patients were divided into two groups based on the median BSI: group 1 BSI < 0.0816 and group 2 BSI > 0.0816. During an average follow-up period of 40.1 ± 19.2 mo (range 12-88 mo), 36 (25.4%) patients had died. The Cox regression analysis of independence showed that increased age (hazard ratio [HR], 1.077, 95% confidence interval [CI],1.031-1.125; P = 0.001), presence of diabetes (HR, 2.855, 95% CI, 1.258-6.481; P = 0.012), hemoglobin (HR, 0.629, 95% CI, 0.452-0.875; P = 0.006), and albumin (HR, 0.442, 95% CI, 0.204-0.955; P = 0.038) were independently related with mortality. None of the anthropometric parameters including BSI were related with mortality. Kaplan-Meier analysis showed that there were no differences with respect to mortality among patients in group 1 and group 2 based on median BSI (P = 0.332, log-rank test). CONCLUSION: In conclusion, BSI is not independently associated with mortality in HD patients.

Does spironolactone ameliorate trastuzumab-induced cardiac toxicity?

The ErbB2 receptor is a proto-oncogene associated with a poor prognosis in breast cancer. Trastuzumab, a humanized anti-ErbB2 antibody currently in clinical use, has proven to be an essential tool in the immunotherapy of breast carcinoma. Additionally, ErbB2 is involved in the growth and survival pathway of adult cardiomyocytes which accounts for the trastuzumab-induced cardiotoxicity. Moreover, in metastatic breast cancer patients treated with trastuzumab, endomyocardial biopsy documented focal vacuolar changes, pleomorphic mitochondria, myocardial cell hypertrophy, and mild interstitial fibrosis on electron microscopy without accompanying light microscopic abnormalities, a finding consistent with a reversible pattern of cardiac injury. On the other hand, aldosterone and mineralocorticoid receptor (MR) researches have experienced a revival after the discovery that aldosterone and MR are not only involved in the electrolyte and volume balance but also in the pathophysiological processes of the reno-cardiovascular system. Aldosterone has both genomic and nongenotropic effects on epidermal growth factor receptor (EGFR) expression. Genomic effect induces genomic up-regulation of the EGFR protein expression via EGFR promoter, whereas nongenotropic effect leads to the EGFR transactivation resulting in persistent pathophysiological effects including formation of extracellular matrix and myocardial hypertrophy. Spironolactone, an aldosterone receptor antagonist, is known to ameliorate the cardiac damage. The underlying mechanism for the genomic interactions seem to be the stimulation of the EGFR promoter by aldosterone-bound MR, which then dose-dependently enhances the EGFR protein levels, which may be successively inhibited by spironolactone. By the light of these findings, we hypothesize that spironolactone may ameliorate trastuzumab-induced cardiotoxicity via inhibition of transactivation of the EGFR by aldosterone and reversing myocardial hypertrophy. This issue warrants further studies.

Bone pain assessment and relationship with parathyroid hormone and health-related quality of life in hemodialysis.

Renal osteodystrophy is a common problem in renal failure patients. Bone pain is a common manifestation of renal osteodystrophy. The aim of the study was to assess the intensity of chronic bone pain via visual analog scale (VAS) and its relationship with parathyroid hormone, health-related quality of life (HRQoL), and depression in hemodialysis patients. Ninety-five patients recruited were asked to rate chronic bone pain via VAS. Depressive symptoms and HRQoL were assessed by Beck Depression Inventory (BDI) and Short-Form 36, respectively. VAS was positively correlated with intact parathyroid hormone (r = +0.322, p = 0.001), phosphorus (r = +0.300, p = 0.003), alkaline phosphatase (r = +0.275, p = 0.009), and negatively correlated with physical component (r = -0.320, p = 0.002) and mental component summary scores (r = -0.247, p = 0.016). In multivariate linear regression analysis, logVAS was independently associated with serum phosphorus (ß = 0.072, 95% confidence interval: 0.020-0.123, p = 0.007), log intact parathyroid hormone (ß = 0.176, 95% confidence interval: 0.041-0.310, p = 0.011), and physical component summary score (ß = -0.018, 95% confidence interval: -0.031-(-0.005), p = 0.008). VAS is correlated with bone metabolism markers, namely, intact parathyroid hormone, and may be used to assess the intensity of chronic bone pain. The intensity of chronic bone pain is related with HRQoL in hemodialysis patients.

The relationship between sleep quality and daytime sleepiness and various anthropometric parameters in stable patients undergoing hemodialysis.

OBJECTIVE: This study evaluates the relationship between sleep quality and daytime sleepiness and body mass index (BMI), waist circumference (WC), waist to hip ratio (WHR), and conicity index in stable patients undergoing hemodialysis (HD). DESIGN AND METHODS: This was a cross-sectional study. Patients regularly received dialysis treatment in a state hospital. Study participants had a medical history taken and underwent physical examination, measurement of anthropometric factors, and calculations (including BMI, WC, WHR, and confidence interval [CI]) and biochemical analysis. We evaluated quality of life with the 36-item short form survey (SF-36) and depressive symptoms with the Beck Depression Inventory (BDI). Self-reported sleep quality (using the Pittsburgh Sleep Quality Index [PSQI]) and daytime sleepiness (using the Epworth Sleepiness Scale (ESS) was recorded for all patients. RESULTS: In total, 101 patients undergoing HD were enrolled. Stepwise linear regression analysis of factors revealed that BMI (b [partial regression coefficient], 0.405; CI, 0.177-0.632; P, .001), WC (b, 0.082; CI, 0.008-0.157; P, .031), BDI score (b, 0.091; CI, 0.032-0.149; P, .003), presence of diabetes (b, 1.621; CI, 0.175-3.068; P, .028), and presence of cerebrovascular disease (b, 1.944; CI, 0.103-3.785; P,.039) were related to PSQI score (as a dependent variable). Using the same independent parameters, only the physical component summary score of the SF-36 was independently related to the ESS score (b, -0.120; CI, -0.190 to -0.049; P, .001). None of the anthropometric parameters was related to ESS. CONCLUSIONS: BMI and WC were the only parameters found to be related to sleep disturbance. None of the anthropometric parameters was related to daytime sleepiness.

The independent relationship between creatinine clearance, microalbuminuria and circadian blood pressure levels in newly diagnosed essential hypertensive and type 2 diabetic patients.

BACKGROUND AND OBJECTIVES: Increased evidence suggests that apart from patients with increased albumin excretion and decreased glomerular filtration rate (GFR); there are also patients with type 2 diabetes with decreased GFR but without albuminuria. The exact pathophysiologic mechanisms regarding these clinical conditions are not known. We suggest that different blood pressure (BP) levels may be one the factors for these different clinical conditions. However, before labeling BP as a causative factor; one must show whether BP levels are different in these patients. Thus the current study was performed to analyze the relationship between creatinine clearance, microalbuminuria and circadian blood pressure levels in newly diagnosed essential hypertensive and type 2 diabetic patients. METHODS: Medical history, physical examination, laboratory analysis and ambulatory blood pressure measurements (ABPMs) were analyzed. 24-h urine specimens were collected to measure creatinine clearance and albumin excretion RESULTS: In total 216 patients were included which were divided into 4 groups: group 1 composed of 90 patients with normal GFR and without microalbuminuria (MA), group 2 composed of 50 patients with normal GFR and with MA, group 3 composed of 36 patients with decreased GFR and without MA and group 4 composed of 40 patients with both decreased GFR and MA. The ratio of dippers vs. non dippers was not different between group 1, group 2 and group 3 patients. However ratio of dippers was higher in group 1 when compared to group 4 (P: 0.003) and group 4 patients have an odds of 7.678 (CI: 1.657-35.576, P: 0.009) for non-dapping status when compared to patients in group 1. CONCLUSION: In conclusion, ABPM measurements were highest in patients with both decreased GFR and MA, whereas they are lowest in patients with normal GFR and normal UAE.

The primary arteriovenous fistula failure-a comparison between diabetic and non-diabetic patients: glycemic control matters.

OBJECTIVES: Presence of diabetes mellitus has been shown to be related with the occurrence of primary arteriovenous fistula (AVF) failure in some but not in all studies. In the current study, we examined whether glycemic control as evaluated by HbA1c is independently related with primary AVF failure. METHODS: We recorded sociodemographic, clinical, and laboratory parameters of the patients from medical records and hospital charts prior to AVF surgery. Primary AVF failure was described as a complication of the AVF before the first successful cannulation for HD treatment. RESULTS: Our study comprised of 160 non-diabetic (Group1) and 73 diabetic patients. Among diabetic patients, 37 had HbA1c values <7% (Group 2) and 36 patients had HbA1c values ≥7% (Group 3). In total, 74 (31.8%) patients had a history of primary AVF failure. The percentages of primary AVF failure were 27.5, 29.7, and 52.8% in Group 1, Group 2, and Group 3, respectively (P: 0.013). The percentage of patients with primary AVF failure was significantly lower in Group 1 and Group 2 than in Group 3 (P:0.003 and P:0.045, respectively). There was no difference with respect to primary AVF failure between Group 1 and Group 2 patients. CONCLUSIONS: We suggest that poor glycemic control as assessed by HbA1c may be an important factor for the development of primary AVF failure among diabetic subjects. It is possible that differences with respect to AVF failure between diabetic and non-diabetic patients may be partly attributed to glycemic control.

The relationship between breakfast, lunch and dinner eating pattern and hemodialysis sessions, quality of life, depression and appetite in hemodialysis patients.

OBJECTIVE: To evaluate the relationship between eating pattern (regular breakfast, lunch and dinner) and dialysis sessions, laboratory and sociodemographic characteristics in hemodialysis (HD) patients. MATERIALS AND METHODS: In this cross-sectional study eating patterns, sociodemographic, laboratory and clinical parameters, depressive symptoms, quality of life, cognitive function and appetite status were assessed. RESULTS: Eighty-two HD patients on morning session and 60 patients on midday HD session schedules were included. Ten patients had only breakfast, 17 patients had only lunch, 26 patients had only dinner, 5 patients had breakfast and lunch but not dinner, 28 patients had breakfast and dinner but not lunch, 29 patients had lunch and dinner but not breakfast, and 19 patients had neither breakfast, nor lunch, nor dinner. In the whole group, only 8 patients reported that they had regularly eaten breakfast, lunch or dinner in all days of the week. Midday HD session, better appetite, and higher income were independently associated with having breakfast. Morning HD session, better appetite score, and higher income were independently associated with having lunch. Morning session versus midday session, nPNA, presence of hypertension, and the Mental Component Summary Score of SF-36 were independently associated with having dinner. CONCLUSION: The majority of HD patients eat one or two meals per day. Having breakfast (or lunch) is associated with midday dialysis session (or morning dialysis session, respectively), better appetite, and satisfactory income. Eating dinner was associated with morning dialysis session, hypertension, higher protein intake and higher SF-36 mental component summary score.

Vascular access type, health-related quality of life, and depression in hemodialysis patients: a preliminary report.

PURPOSE: Arteriovenous fistulas (AVF) are the vascular access of choice for hemodialysis (HD) compared with arteriovenous grafts (AVG) and central venous catheters (CVC). In spite of increasing recognition of importance of a patient's perception of health-related quality of life (HRQOL) and depression, few studies have assessed the association of vascular access type with HRQOL and depression. The purpose of our study was to examine HRQOL and depression among patients with different vascular access. METHODS: Severity of symptoms of depression and HRQOL were assessed by Beck Depression Inventory (BDI) and Short Form-36 (SF-36), respectively. Vascular access was reported as one of three options; AVF, AVG, and CVC. RESULTS: In total, 136 patients were included; 104 had AVF, 15 had AVG, and 17 had CVC. BDI and HRQOL parameters differed among patients with different vascular access types. In post hoc analysis, BDI and HRQOL subscales were not different between patients with AVF and AVG. Patients with CVC had lower physical functioning (P:.001), role-physical limitation (P:.015), general health perception (P:.017), vitality (P:.010), social functioning (P:.004), role-emotional (P:.008), mental health (P:.001), physical component summary score (P:.017), and mental component summary score (P:.006) when compared to patients with AVF. Patients with CVC had lower physical functioning (P:.044), role-emotional (P:.044) and mental health scores (P:.04) when compared to patients with AVG. CONCLUSIONS: Having a CVC may negatively influence HRQOL in HD patients. Vascular access type does not seem to be related to depressed mood in HD.

Relationship between uric acid and subtle cognitive dysfunction in chronic kidney disease.

BACKGROUND: Elevated serum uric acid has been associated with cognitive dysfunction and vascular cognitive impairment in the elderly. Serum uric acid is also commonly elevated in chronic kidney disease (CKD), but its relationship with cognitive function in these patients has not been addressed. METHODS: Subjects with CKD (defined as eGFR <60/ml/min/1.73 m(2)) were evaluated for cognitive dysfunction using the validated Standardized Mini-Mental State Examination (SMMSE). Individuals with dementia, depression or other psychiatric disorders were excluded, as were subjects on uric acid-lowering therapy or with serious illnesses such as severe anemia or active or ongoing cardiovascular or cerebrovascular disease. RESULTS: 247 subjects were enrolled. SMMSE scores showed stepwise deterioration with increasing quartile of serum uric acid (26.4; 26.1; 25.5; 25.3, score range 20-30, p = 0.019). Post-hoc analysis demonstrated that there was no linear trend and only groups 1 and 4 were different with respect to SMMSE scores (p = 0.025). Stepwise multivariate linear regression revealed that age, educational status, presence of cerebrovascular disease, and serum uric acid were independently related to SMMSE scores. CONCLUSION: Serum uric acid levels are independently and inversely associated with mild cognitive dysfunction in subjects with CKD.

Which anthropometric parameter is best related with urinary albumin excretion and creatinine clearance in type 2 diabetes: body mass index, waist circumference, waist-to-hip ratio, or conicity index?

OBJECTIVE: We analyzed the relationships between body mass index (BMI), waist circumference (WC), waist-to-hip ratio, and conicity index and 24-hour urinary albumin excretion rate (UAER) and creatinine clearance. DESIGN: Cross-sectional study. SETTING: Patients presenting to a state hospital. PATIENTS: Study involved patients with type 2 diabetes. METHODS: Study participants underwent medical history examination, measurement of office blood pressure (BP), measurement of anthropometric factors and calculations (including BMI, WC, waist-to-hip ratio, and conicity index), physical examination, biochemical analysis, and 24-hour urine specimen collection to determine creatinine clearance and UAER. RESULTS: In all, 202 patients with type 2 diabetes (male/female: 91/111, aged: 58.4 ± 10.1 years) were included. It was found that 24-hour UAER correlated with WC (rho: +0.176, P = .012), serum albumin (rho: -0.324, P < .0001), and systolic BP (rho: +0.153, P = .029), whereas creatinine clearance correlated with age (rho: -0.152, P = .031), BMI (rho: +0.191, P = .007), albumin level (rho: +0.365, P < .0001), and uric acid level (rho: -0.369, P < .0001). The stepwise linear regression analysis revealed that WC (P = .012), glycosylated hemoglobin (P = .018), and systolic BP (P = .043) were found to be independently related to logarithmically converted 24-hour UAER, whereas creatinine clearance was found to be related to duration of diabetes (P = .001), BMI (P = .008), presence of peripheral arterial disease (P = .021), fasting serum glucose level (P = .003), and uric acid level (P < .0001). However, after correction for body surface area, BMI was no longer associated with creatinine clearance. CONCLUSION: Among the anthropometric parameters, only an increase in WC was found to be independently related to 24-hour UAER. Although BMI was associated with creatinine clearance, this association was lost after creatinine clearance was corrected for body surface area.