Abnormal diurnal blood pressure profile and hypertension-mediated organ damage in nondiabetic chronic kidney disease G1-G3b patients.

OBJECTIVE: Chronic kidney disease (CKD) is associated with high cardiovascular risk. Prevalence of hypertension and hypertension-mediated organ damage (HMOD) increases with CKD progression. Nocturnal blood pressure (BP) is a strong predictor of cardiovascular complications. This cross-sectional study investigated the link between the diurnal BP profile and HMOD in nondiabetic CKD G1-G3b patients. METHODS: We investigated 109 CKD patients and 41 apparently healthy persons as controls. All subjects underwent 24-ambulatory blood pressure monitoring (ABPM), echocardiography with left ventricular mass index (LVMI) calculation and pulse wave velocity (PWV) measurement. RESULTS: Hypertension was present in 84% of CKD patients. SBP-24 and DBP-24, SBP-day and DBP-day did not differ between CKD and controls. Significant differences were found in SBP-night and DBP-night. The nondipping BP profile (SBP-night/SBP-day ratio ≥0.9) was found in 62% of CKD patients and 32% of controls (P < 0.005). Nocturnal hypertension was found in 56% of CKD patients. LVMI was higher in CKD compared to controls, higher in nondipping than dipping CKD patients, and higher in patients with nocturnal hypertension than without nocturnal hypertension. Abnormal left ventricular geometry was found in 72% nondipping and 43% dipping CKD patients. PWV was higher in CKD than in controls, in patients with nocturnal hypertension than without nocturnal hypertension but did not differ between CKD nondippers and dippers. CONCLUSION: The nondipping BP profile and nocturnal hypertension are associated with HMOD in G1-G3b CKD patients. Hence, there is a need for more extensive use of ABPM for individual risk assessment and personalization of antihypertensive treatment in CKD patients.

Assessment of Peritoneal Membrane Arteriolar Structure in Conjunction with Traditional Cardiovascular System Evaluation in Chronic Kidney Disease (CKD) Stage 5 Patients.

BACKGROUND/AIMS: Cardiovascular complications are responsible for increased mortality and morbidity in chronic kidney disease (CKD) patients. Functional and structural changes of peritoneal membrane are reported in CKD patients both on conservative treatment and on renal replacement therapy (RRT). The aim of the study was to assess the structure of peritoneal membrane small arteries (precapillary arterioles) in diabetic and non-diabetic CKD stage 5 patients before initiation of peritoneal dialysis (PD) and evaluate its relationship with heart and large arteries abnormalities and with selected biochemical parameters. METHODS: Evaluation of 42 CKD stage 5 patients before starting PD. Diabetic (n=26) and non-diabetic (n=16) patients were compared. Peritoneal membrane samples were taken during Tenckhoff catheter insertion. Histopathological evaluation of peritoneal precapillary arterioles (arteriolar evaluation) with measurement of wall thickness (WT) and calculation of lumen/vessel (L/V) ratio was performed in each patients. Echocardiography, intima media thickness (IMT), pulse wave velocity (PWV), ambulatory blood pressure monitoring (ABPM) and biochemical parameters assessment: serum albumin (SA), total cholesterol (TCH), hemoglobin (Hgb), parathormone (PTH), serum calcium (Ca), serum phosphorus (P), transferrin saturation (TSAT%), C-reactive protein (CRP) were performed in each participant. RESULTS: There were no statistically significant differences in peritoneal membrane arteriolar indices - wall thickness (WT) and L/V ratio between investigated groups. There was statistically significant higher PWV value in diabetic patients. There were no statistically significant differences in echocardiographic indices, IMT, laboratory data in analyzed groups. There were some linear correlations between: PWV vs IMT (R=0,84; p=0,0006); PWV vs PP (R=0,58; p=0,03) in non-diabetic and linear correlation between: PWV vs age (R=0,75; p=0,02); WT vs DP (R=-0,93; p=0,001); WT vs DBP ( R=0,64; p=0,04) in diabetic group. CONCLUSION: Peritoneal membrane arteriolar damage seems to be an integrated part of cardiovascular system damage in CKD stage 5 patients.

Aldosterone antagonist therapy and its relationship with inflammation, fibrosis, thrombosis, mineral-bone disorder and cardiovascular complications in peritoneal dialysis (PD) patients.

BACKGROUND: High aldosterone level may contribute to pathogenesis of hypertension, vessels damage and cardiovascular system deterioration in chronic kidney disease patients. Besides its classical action via mineralocorticoid receptor, aldosterone is also involved in cell growth, inflammation, oxidative stress, endothelial dysfunction and exerts fibroproliferative effects. The aim of the study was to assess whether aldosterone antagonist treatment may influence serum level of inflammatory, fibrosis, thrombosis and mineral-bone metabolism markers in peritoneal dialysis (PD) patients and blood pressure, aortic stiffness, echocardiographic indices after 12 months of treatment. METHODS: Twenty-two patients on PD were assigned to spironolactone treatment in dose of 50 mg daily during 12 months. Fifteen PD patients were assigned to control group. Echocardiographic indices, PVW, SBP, DBP (mean values from ABPM) and biochemical parameters such as: aldosterone, osteopontin, IL-6, selectin-P, TGF-ß, PTH, MMP-2 were performed at the beginning and after 12 months in spironolactone and control group. RESULTS: There were no statistically significant differences in echocardiographic indices, PWV, BP (ABPM readings) and biochemical markers: MMP-2, serum aldosterone, TGF-ß, IL-6, selectin-P, PTH level after 12 months of spironolactone treatment. There was statistically significant rise in osteopontin level after 12 months of spironolactone treatment. Episodes of life-threatening hyperkalemia were not reported. CONCLUSIONS: Aldosterone antagonists use in PD patients seems to be safe. Longer duration or higher dosage of spironolactone seems to be more effective in improving cardiovascular system status in PD patients. Further studies are required to determine relationship between mineralocorticoid receptor blockade and mineral-bone disturbances in PD patients.

Beneficial Effects of 6-Month Supplementation with Omega-3 Acids on Selected Inflammatory Markers in Patients with Chronic Kidney Disease Stages 1-3.

INTRODUCTION: Chronic kidney disease (CKD) is accompanied by inflammation. The aim of this study was to evaluate the effect of 6-month supplementation with omega-3 acids on selected markers of inflammation in patients with CKD stages 1-3. METHODS: Six-month supplementation with omega-3 acids (2 g/day) was administered to 87 CKD patients and to 27 healthy individuals. At baseline and after follow-up, blood was taken for C-reactive protein (CRP) and monocyte chemotactic protein-1 (MCP-1) concentration and white blood cell (WBC) count. Serum concentration of omega-3 acids-eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and alpha-linolenic acid (ALA)-was determined using gas chromatography. And 24-hour urinary collection was performed to measure MCP-1 excretion. RESULTS: After six-month omega-3 supplementation, ALA concentration increased in CKD patients and in the reference group, while EPA and DHA did not change. At follow-up, a significant decrease in urinary MCP-1 excretion in CKD (p = 0.0012) and in the reference group (p = 0.001) was found. CRP, serum MCP-1, and WBC did not change significantly. The estimated glomerular filtration rate (eGFR) did not change significantly in the CKD group. CONCLUSIONS: The reduction of urinary MCP-1 excretion in the absence of MCP-1 serum concentration may suggest a beneficial effect of omega-3 supplementation on tubular MCP-1 production. TRIAL REGISTRATION: This study was registered in ClinicalTrials.gov (identifier: NCT02147002).

Left ventricular remodeling and arterial remodeling in patients with chronic kidney disease stage 1-3.

INTRODUCTION: Chronic kidney disease (CKD) is an independent factor for cardiovascular system complications, such as arterial hypertension, left ventricular hypertrophy (LVH), heart failure or accelerated atherosclerosis progression. The aim of the paper was to analyze left ventricular and arterial remodeling in patients with CKD stages 1-3 to identify the subclinical marker of cardiovascular system damage which changes first in the course of CKD. METHODS: The examined group consisted of 90 patients with CKD stage 1-3 and 30 subjects constituting the control group. Left ventricular mass index (LVMI), left ventricular relative wall thickness (RWT) and ejection fraction (EF) were determined by echocardiographic examination. Pulse wave velocity (PWV) between the carotid and femoral arteries as well as common carotid artery intima-media thickness (IMT) was measured. 24-h ambulatory blood pressure monitoring was performed in all subjects. RESULTS: No differences were found between blood pressure values in the examined groups of patients with CKD1, CKD2 and CKD3. Concentric remodeling was found in 20.0%, concentric hypertrophy in 22.2% and eccentric hypertrophy in 18.9% of patients. LVMI values in patients with CKD2 and 3 were higher than in the control group. IMT values in patients with CKD3 were higher than in patients with CKD2. PWV in patients with stage 3 CKD was significantly higher than in the control group (p < 0.05). CONCLUSIONS: In the course of CKD, the left ventricle undergoes remodeling earlier than large arterial vessels. Echocardiographic assessment of LVH in early stages of CKD may identify patients at increased cardiovascular risk.

Coronary artery calcification and large artery stiffness in renal transplant recipients.

PURPOSE: Coronary artery calcification (CAC) is an independent predictor of cardiovascular (CV) events in renal transplant recipients (RTR). Carotid-femoral pulse wave velocity (PWV), a non-invasive measure of large artery stiffness, also predicts CV events in RTR. The study investigated the relationship between CAC and PWV in RTR and assessed the performance of PWV measurement in predicting CAC. PATIENTS/METHODS: The study was performed as cross-sectional analysis in 104 RTR. CAC was determined as total calcium score (CS) and calcium mass (CM). Carotid-femoral PWV was also measured. Sensitivity, specificity and receiver operating characteristic (ROC) curve were used to assess the performance of PWV as diagnostic test for presence of CAC. RESULTS: CAC was found in 69% of participants. PWV was higher in RTR with CAC than in RTR without CAC (10.2±2.2 vs. 8.6±15; p<0.001). In univariate analysis CS was significantly correlated with age, duration of hypertension, waist circumference, PWV, hemoglobin concentration, and serum glucose. In multiple linear regression analysis CS was independently associated with age only, but not with PWV. Sensitivity and specificity of PWV>7.6m/s as cut-off for detecting CAC>0 was 0.889 and 0.406, respectively. Sensitivity and specificity of PWV>10.2m/s as cut-off for detecting severe CAC (CS>400) was 0.319 and 0.969, respectively. CONCLUSIONS: The study confirmed high prevalence of coronary artery calcification in renal transplant recipients. The study does not support the hypothesis that aortic stiffness is independently associated with coronary artery calcification in RTR. PWV measurement may be useful in excluding severe CAC in RTR.

Abdominal collateral vein as an unconventional vascular access for hemodialysis in patient with central vein occlusion.

A 65-year-old female patient with chronic kidney disease stage 5 and a history of spleen neoplasm with dissemination within peritoneum is presented. During 5 years of hemodialysis therapy, bilateral occlusion of brachiocephalic and iliac vein developed as a consequence of vein catheterization. An attempt to cannulate inferior vena cava was unsuccessful. A cannulation of dilated collateral abdominal veins with dialysis needles allowed to perform several hemodialysis sessions in the patient.

25-hydroxyvitamin D, biomarkers of endothelial dysfunction and subclinical organ damage in adults with hypertension.

BACKGROUND: The mechanism that underlies the association between low 25-hydroxyvitamin D [25(OH)D] and hypertension is not well understood; it seems to involve regulation of the renin-angiotensin-aldosterone system and the impact on endothelial function, cardiac remodeling, and subclinical organ damage. Vitamin D supplementation presents an ambiguous effect on endothelial function and arterial stiffness. We assess serum 25(OH)D3, biomarkers of endothelial dysfunction (soluble intercellular adhesion molecule [sICAM], C-reactive protein [CRP], homocysteine [Hcy]) and subclinical organ damage in adults with newly diagnosed untreated hypertension. METHODS: Patients were classified based on ambulatory blood pressure monitoring: 98 had hypertension, whereas in 60 persons BP was normal. Laboratory assays including serum 25(OH)D3, hsCRP, Hcy, sICAM, glucose, insulin, lipids, echocardiography, pulse wave velocity (PWV), intima-media thickness (IMT), and left-ventricular mass (LVM) measurements were performed. RESULTS: 25(OH)D3 was significantly lower in hypertensive patients. The logistic regression analysis indicated that 25(OH)D3 reduced the probability of hypertension occurrence after adjusting for body mass index (BMI). 25(OH)D3 in those with hypertension correlated significantly with systolic BP (SBP; r = -0.39), PWV, IMT (r = -0.33), and diastolic BP (r = -0.26). Multiple regression analysis in patients with hypertension revealed that 25(OH)D3 and sICAM accounted for up to 27% of SBP variation after adjusting for age, BMI, and smoking. 25(OH)D3 and either PWV or IMT accounted for 23% of SBP variation. The impact of 25(OH)D3 was 10%. CONCLUSION: The impact of 25(OH)D3 on SBP variation, mediated by its effect on endothelial dysfunction and subclinical organ damage, is modest but significant.

Advanced glycation end products and arterial stiffness in patients with diabetic nephropathy and patients with chronic kidney disease without diabetes.

INTRODUCTION:  Formation of advanced glycation end­products (AGEs) is increased in diabetic patients. Impaired renal function also elevates AGE accumulation. Pulse wave velocity (PWV) is a measure of arterial stiffness and a prognostic parameter. An association between AGEs and arterial stiffness was observed in hemodialyzed patients. OBJECTIVES:  We investigated the relationship between plasma AGE concentration and arterial stiffness in nondialyzed patients with diabetic nephropathy and those with chronic kidney disease (CKD) without diabetes. PATIENTS AND METHODS:  PWV measurement was performed in 24 patients with CKD and diabetic nephropathy (DN), 36 patients with CKD and without diabetes, and 19 controls. To assess AGE concentrations, plasma fluorescence spectra were recorded.  RESULTS:  Patients with and without diabetes did not differ with respect to the glomerular filtration rate (33 ±13 vs. 32 ±14 ml/min/1.73 m2, respectively). The AGE concentration was significantly higher in patients with DN compared with those without diabetes and controls (21.1 ±6.8 vs. 12.3 ±3.1 vs. 7.8 ±1.2 AU/ml, respectively; P <0.001). PWV was also significantly higher in patients with DN compared with those without diabetes and controls (13.7 ±4.3 vs. 10.1 ±2.4 vs. 8.4 ±1.6 m/s, respectively; P <0.05). A significant correlation was found between AGEs and PWV (r = 0.39, P <0.01) in patients with CKD. In a multiple regression analysis, PWV was independently associated with age, DN, and systolic blood pressure, but not with AGEs (R2 = 0.45).  CONCLUSIONS:  Accumulation of AGEs and arterial stiffness are increased in patients with CKD, particularly in those with DN; however, the results are not sufficient to confirm the causal role of AGE accumulation in arterial stiffening in CKD. AGEs should be considered as a potential therapeutic target in patients with CKD.

Bilateral nephrectomy as a rescue therapy for hemodialyzed patient with malignant hypertension - case report.

We present the case of a 64-year-old male patient in whom malignant phase of hypertension developed during dialysis therapy. Hypertension was resistant to pharmacological therapy with seven antihypertensive drugs and dialysis therapy with ultrafiltration. In this patient bilateral nephrectomy was performed as a rescue therapy. It led to better control of blood pressure and allowed to reduce the number and dosage of antihypertensive medications.

Comparison of arterial stiffness in end­stage renal disease patients treated with peritoneal dialysis or hemodialysis.

INTRODUCTION: Dialysis patients presents increased arterial stiffness. Results of available studies comparing arterial stiffness in peritoneal dialysis (PD) patients vs hemodialysis (HD) patients are inconsistent. OBJECTIVES: The aim of the study was to compare pulse wave velocity (PWV) in PD and HD patients and to compare value of measured PWV (PWV(M)) with theoretical value of this parameter (PWV(T)) calculated using formula developed by Blacher et al. From the equation it is apparent that PWV increases by 0.8 m/s for each decade of life. PATIENTS AND METHODS: Carotid-femoral PWV(M) was measured in 35 PD and 26 HD patients, using Complior device. In all patients PWV(T) was also calculated. RESULTS: The study groups did not differ significantly with respect to age, gender, and prevalence of diabetes. The value of PWV(M) (PD:12.1 ± 3.3 vs HD:12.0 ± 3.0 m/s) and PWV(T) (PD:10.0 ± 1.4 vs HD:9.9 ± 1.2 m/s) did not differ significantly between PD and HD. PWV(M) was significantly higher than PWVT in both, PD and HD patients. Diastolic blood pressure and mean arterial pressure was higher in PD patients, but systolic blood pressure and pulse pressure did not differ significantly. In PD patients a higher number of antihypertensive medications was used (3 ± 1 vs 2 ± 1;p<0.05). CONCLUSIONS: Arterial stiffness is equally high in peritoneal dialysis patients and in hemodialysis patients. Measured value of PWV in both, PD and HD patients, is significantly higher when compared with theoretical value of PWV. This finding may reflect accelerated arterial aging in patients on dialysis.

Progressive arterial stiffening in kidney transplant recipients.

BACKGROUND: Pulse wave velocity (PWV) is a marker of arterial stiffness. Data from general population and end-stage renal disease patients suggest that PWV increases with age by about 0.1 m/s for each year of life and that PWV increase is steeper after the fifth decade. Recent follow-up studies showed decrease of arterial stiffness during the first year after kidney transplantation (KTx). This study aimed to investigate PWV change in kidney transplant recipients (KTR) during long-term follow-up. MATERIAL/METHODS: Carotid-femoral PWV was measured at baseline (PWV1) and then after at least 24 months (range 24-34, mean ±SD 28±3) of follow-up (PWV2) in 61 KTR aged 46±12 years. Baseline PWV measurements were performed at 36±27 months (range 4-121) after KTx. Clinical and laboratory data were also analyzed. GFR was calculated with MDRD formula (eGFR). ∆PWV was calculated as (PWV2-PWV1)/PWV1. RESULTS: Significant increase in PWV (9.1±1.7 vs. 9.8±2.0; p<0.002) and pulse pressure (PP) (50±11 vs. 53±14; p<0.05) was found during follow-up, but systolic, diastolic and mean arterial pressure did not change. eGFR did not change during follow-up (55±16 vs. 56±16 ml/min/1.73 m2). PWV increase was observed in patients aged ≥50 years (9.8±1.8 vs. 10.8±1.9; p<0.01), while not in younger patients (8.5±1.5 vs. 8.9±1.5; p=0.14). Significant positive correlation was found between ∆PWV and duration of the follow-up period. CONCLUSIONS: The study revealed progressive arterial stiffening in kidney transplant recipients during long-term follow-up. Further studies are necessary to explain the pathophysiology of this phenomenon.

High incidence of nephropathy in neurosurgical patients after intra-arterial administration of low-osmolar and iso-osmolar contrast media.

BACKGROUND: Percutaneous endovascular examinations and interventions require significant amounts of iodinated contrast media (CM) and have been reported to be complicated by an increased incidence of post-contrast nephropathy. PURPOSE: To evaluate renal function, the incidence of post-contrast nephropathy, and risk factors after interventional procedures in neurosurgical patients after intra-arterial administration of a low-osmolar contrast medium (LOCM) versus an iso-osmolar contrast medium (IOCM). MATERIAL AND METHODS: This single-center, prospective, randomized, double-blinded study included 92 patients in its final analysis (mean age 49.6 ± 12.6 years, 29.3% men, mean eGFR 97.8 ± 26.3 mL/min/1.73 m(2)). LOCM was used in 48 patients (52.2%) and IOCM in 44 patients (47.8%). The patients were given an average of 151.2 ± 52.1 mL of contrast medium intra-arterially. Serum creatinine (SCr), urinary N-acetyl-ß-glucosaminidase (NAG) excretion, and creatinine clearance (CCr) were measured at baseline, and on days 1 and 3 after the procedure. RESULTS: Baseline risk factors, renal functional parameters, and average CM doses were not statistically different between the two groups. SCr, NAG, and CCr values did not differ significantly between the LOCM and IOCM groups on days 1 and 3 after CM administration. Nephropathy developed in 21 cases (22.8%): 13 (27.1%) after LOCM use and 8 (18.2%) after IOCM; (P = NS). The only significant risk factors of CIN were the diabetes (P = 0.0466) and atherosclerosis (P = 0.0498). CONCLUSION: We found a high incidence of nephropathy in neurosurgical patients after intra-arterial CM administration. The renal function values and incidence of nephropathy following LOCM administration were not statistically different from those following IOCM administration.

Factors associated with increased arterial stiffness in renal transplant recipients.

BACKGROUND: Pulse wave velocity (PWV) is a marker of arterial stiffness. It was shown that PWV is related to increased cardiovascular risk in renal transplant recipients (RTR). Renal transplantation leads to decrease of arterial stiffness when compared with dialysis patients. Despite many studies, causes of increased arterial stiffness in RTR are not well defined. This study sought to investigate the association between cardiovascular risk factors, graft function, cardiovascular and immunosuppressive therapy, and carotid-femoral PWV in renal transplant recipients. MATERIAL/METHODS: Carotid-femoral PWV were measured with Complior device in 207 (73 female and 134 male) RTR aged 45+/-12 years, and in 21 healthy volunteers as controls. RESULTS: Pulse wave velocity was higher in RTR compared with controls: 9.2+/-2.1 m/s vs 8.3+/-1.5m/s (P<.05). In RTR group, significant correlations were found between PWV and age (r=0,55; P<.001), male sex (r=0.17; P<.02), body weight (r=0.23; P<.01), systolic (SBP) (r=0.36; P<.001), and diastolic blood pressure (DBP) (r=0.19; P<.01), pulse pressure (pulse pressure) (r=0.34; P<.001), mean arterial pressure (MAP) (r=0.28; P<.001), number of antihypertensive medication (r=0.17; P<.02), fasting glucose (r=0.24; P<.01), presence of diabetes (r=0.24; P<.01), eGFR (r=-0.19; P<.01), therapy with cyclosporine (r=0.29; P<.001), and therapy with tacrolimus (r=-0.22; P<.01). In stepwise multiple regression analysis, age, male sex, MAP, cyclosporine, and fasting glucose concentration were independently associated with increased PWV. CONCLUSIONS: Arterial stiffness is increased in RTR. Type of immunosuppressive regimen, high blood pressure, and glucose metabolism disturbances should be considered as potential targets to reduce increased arterial stiffness in RTR.

Influence of the 6-month anemia therapy with erythropoietin on renal function and some hemodynamic parameters in predialysis patients.

OBJECTIVES: The aim of this study was to evaluate the influence of a 6-month anemia therapy with recombinant human erythropoietin (rHuEpo) on glomerular filtration rate (GFR) and renal blood flow related to hemoglobin (Hb) concentration, changes in heart function and total peripheral resistance in patients with chronic kidney disease (CKD) treated conservatively. PATIENTS AND METHODS: We evaluated 13 patients (9 women and 4 men) aged 64.8 +/- 8.9 years with serum creatinine of 3.82 +/- 1.30 mg/dl and Hb concentration of 10.02 +/- 0.45 g/dl. rHuEpo was given in the mean dose of 2296 +/- 673 U/week s.c. to achieve Hb 12 g/dl. At baseline and after 6 months of rHuEpo therapy echocardiography and renoscintigraphy were performed. RESULTS: After 6 months' therapy Hb increased significantly, while blood pressure did not change significantly. Renal anemia correction led to a decrease in left ventricular end-diastolic dimension index, left ventricular end-diastolic volume index, stroke volume index and cardiac index. Total peripheral vascular resistance index increased significantly. At the same time a significantly reduced left ventricular mass index was observed. Correction of renal anemia and changes in systemic hemodynamics did not exert unfavorable effect on renal hemodynamic parameters. GFR index, blood flow rate index, renal vascular resistance index and filtration fraction remained unchanged. During rHuEpo therapy decline in renal function expressed as 1/serum creatinine did not differ compared with a 6-month period before initiating rHuEpo therapy. CONCLUSIONS: Therapy with rHuEpo in patients with stage 3 and 4 CKD with correct blood pressure control does not result in worsening of renal function despite changes in left ventricular function and increase of total peripheral resistance.