Atrial fibrillation in chronic hemodialysis patients: prevalence, types, predictors, and treatment practices in Greece.

Atrial fibrillation (AF), the most common sustained arrhythmia in clinical practice, is associated with increased mortality and cardiovascular morbidity both in nonuremic and (recently) in dialysis patients. The aims of this study are: (i) to assess the prevalence of AF, the risk factors, and predictors of its presence in a cohort of incident hemodialysis (HD) patients in Greece and (ii) to report on current practices in the management of these patients. This is a prospective, cross-sectional, multicenter study of 574 patients on a regular HD program for >6 months. Demographic characteristics, cause of renal disease, cardiovascular risk factors, medication use, dialysis data (Kt/V, dialysis method, type of dialysate), 12-lead electrocardiogram (ECG) (interdialytic day), and cardiac echo data were collected. Pertinent demographic, ECG, and echocardiographic data were entered into univariate and multivariate analyses to evaluate associations with AF. The CHADS2 score (congestive heart failure [HF], hypertension, age ≥ 75, diabetes, previous stroke/transient ischemic attack [TIA]) was estimated and clinical practices in high-risk (CHADS2 score ≥ 2) patients were evaluated. The cohort included 368 men (64.1%) and 206 (35.8%) women (mean age 65.1 ± 14.4 years) with a mean duration on dialysis of 72.1 ± 60.4 months. Hypertension (75.6%) and coronary artery disease (47.2%) were the commonest cardiovascular risk factors for AF. The prevalence of AF was 23.2% and showed an age-dependent increase; in patients <50 years, AF was present in 9.3%, while in patients ≥ 80 years, its prevalence increased to 36.4%. Furthermore, 8.3% of patients had permanent, 1.8% persistent, 12.7% paroxysmal AF, while the prevalence of paroxysmal atrial flutter and sick sinus syndrome were 1.2 and 2%, respectively. Logistic regression analysis showed that age, smoking, left atrial and aortic root diameter, ß-blocker and α-calcidol use, HF, and the presence of valvular calcifications (VC) on cardiac echo were independently associated to the presence of AF. VC on cardiac echo had an almost sevenfold increased association with AF (odds ratio 6.72, 95% confidence interval 3.23-13.98, P < 0.0001). Only 25.5% of high-risk (CHADS2 score ≥ 2) patients were receiving anticoagulants. AF is a frequent arrhythmia in HD patients. Apart from well-known risk factors, VC merits special attention in this patient population. Less than one-third of high-risk AF patients receive anticoagulants, possibly reflecting the absence of definite guidelines for the management of AF in HD patients.

Combination treatment with plasmapheresis and rituximab for recurrent focal segmental glomerulosclerosis after renal transplantation.

Therapy for recurrent focal segmental glomerulosclerosis (FSGS) in the renal allograft is largely based on case reports. The use of plasmapheresis alone (based on its effectiveness in children) appears less effective in adults, reaching a response rate of <40%. Recently, rituximab, an anti-CD20 monoclonal chimeric antibody, showed promising results as rescue therapy in plasmapheresis-resistant recurrent FSGS. However, following rituximab administration, response is variable, often slow and consequently overlooked. We report a series of four cases of recurrent FSGS following renal transplantation successfully treated with a combination of plasmapheresis and rituximab. Complete remission of proteinuria occurred in two and partial remission in the other two patients whereas renal function improved or remained stable. During treatment and the follow-up period (18-60 months) no severe infectious complications were observed. Our data suggest that the combination of plasmapheresis and rituximab is an acceptable treatment in patients with post-transplantation recurrent FSGS.

Long-term prognosis of combined chronic heart failure and chronic renal dysfunction after acute stroke.

AIMS: To assess the prevalence of combined chronic heart failure and chronic renal dysfunction (CHF-CRD) in acute stroke patients and to investigate any prognostic significance on long-term outcome. METHODS AND RESULTS: First-ever acute stroke patients (n = 831) were divided into four groups based on the presence of heart failure (HF, NYHA II-IV with or without left ventricular ejection fraction <40%) and/or renal dysfunction (RD, estimated glomerular filtration rate <60 mL/min/1.73 m(2)). Patients with acute kidney injury and/or acute decompensated HF were excluded. Group 1 comprised patients without HF or RD (nHF + nRD), Group 2 patients with RD but no HF (nHF + RD), Group 3 those with HF and no RD (HF + nRD), whereas Group 4 included patients with both HF and RD (HF + RD). HF and RD were independent predictors of mortality at 10 years. Patients in Groups 2, 3, and 4 had an increased probability of death during follow-up compared with Group 1: HR 1.34 (95% CI 1.02-1.77, P < 0.05) for group 2; HR 2.24 (95% CI 1.50-3.36, P < 0.001) for group 3; and HR 3.42 (95% CI 2.36-4.95, P < 0.001) for group 4. Age, history of transient ischaemic attacks and combined HF and RD were independent predictors of new cardiovascular events. When compared with Group 1, patients in Group 2 had an HR of 1.48 (95% CI 1.11-1.98, P < 0.01), those in Group 3 an HR of 2.21 (95% CI 1.48-3.29, P < 0.001), and those in Group 4 an HR of 3.59 (95% CI 2.40-5.39, P < 0.001). CONCLUSION: The combination of CHF-CRD after acute stroke is an independent predictor for mortality and new cardiovascular morbidity over 10 years.

Fibroblast growth factor 23 (FGF23) and the kidney.

Phosphate homeostasis in humans is a complex phenomenon involving the interplay of several different organs and circulating hormones. Among the latter, parathyroid hormone (PTh), and vitamin D3 (Vit D3) were thought to be the main regulators of serum phosphate concentration since they mediated the intestinal, renal and bone responses that follow fluctuations in serum phosphate levels. The study of three rare disorders - tumor-induced osteomalacia (TIo), autosomal dominant hypophosphatemic rickets (ADhr) and X-linked hypophosphatemic rickets (XLh) - has offered a completely new insight into phosphate metabolism by unraveling the role of a group of peptides that can directly affect serum phosphate concentration by increasing urinary phosphate excretion. fibroblast growth factor-23 (fGf-23) is the most extensively studied ''phosphatonin''. The production, mechanism of action, effects in various target tissues, and its role in common clinical disorders are the focus of this review.

Rapamycin for focal segmental glomerulosclerosis: a report of 3 cases.

Corticosteroids and/or cyclosporine constitute the present therapeutic approach for patients with focal segmental glomerulosclerosis (FSGS). The high incidence of side effects for the former and risk of nephrotoxicity combined with the high relapse rate after discontinuation for the latter render their use problematic. Results concerning the role of rapamycin in the treatment of patients with FSGS are conflicting. We describe results for 3 patients treated with a combination of low-dose steroids and rapamycin for FSGS, focusing on the importance of maintaining low drug (rapamycin) levels by using a twice-daily regimen.

Long-term prognosis of acute kidney injury after first acute stroke.

BACKGROUND AND OBJECTIVES: Acute kidney injury (AKI) has been associated with increased mortality in a variety of clinical settings. We studied the incidence, predictors, and effect of AKI on long-term overall mortality and cardiovascular events after stroke. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This was a prospective outcome study of 2155 patients who sustained an acute first-ever stroke and were followed for 10 yr. Patients were divided in two groups: (1) Those with an acute increase (over 48 h) in serum creatinine >or=0.3 mg/dl or a percentage increase of >or=50% and (2) those with a change <0.3 mg/dl, no change at all, or even a reduction. RESULTS: Twenty-seven percent of patients developed AKI after acute stroke. Stroke severity, baseline estimated GFR, heart failure, and stroke subtype predict the occurrence of AKI. The probability of 10-yr mortality for patients with AKI was 75.9 and 57.7 in the patients without AKI (log rank test 45.0; P = 0.001). When patients with AKI were subdivided into three groups according to AKI severity, the probability of 10-yr mortality increased: 73.7, 86.5, and 89.2 in stages 1, 2, and 3, respectively. In Cox proportional hazard analysis, AKI was an independent predictor of 10-yr mortality (P < 0.01) and for the occurrence of new composite cardiovascular events (P < 0.05) after adjustment for available confounding variables. CONCLUSIONS: AKI after stroke is a powerful and independent predictor of 10-yr mortality and new composite cardiovascular events.

Renal dysfunction in acute stroke: an independent predictor of long-term all combined vascular events and overall mortality.

BACKGROUND: Acute stroke is the third leading cause of death in western societies after ischemic heart disease and cancer. Although it is an emergency disease sharing the same atherosclerotic risk factors with ischemic heart disease, the association of renal function and stroke is poorly investigated. The present study aims at assessing renal function status in patients with acute stroke and investigate any prognostic significance on the outcome. METHODS: This is a prospective study of hospitalized first-ever stroke patients over 10 years. The study population comprised 1350 patients admitted within 24 h from stroke onset and followed up for 1 to 120 months or until death. Patients were divided in 3 groups on the basis of the estimated Glomerular Filtration Rate (eGFR) that was calculated from the abbreviated equation of the Modification Diet for Renal Disease in ml/min/1.73 m(2) of body surface area: Group-A comprised patients who had eGFR > 60, group-B those with 30

Immunosuppressive treatment of idiopathic focal segmental glomerulosclerosis: a five-year follow-up study.

BACKGROUND/AIMS: Focal segmental glomerulosclerosis (FSGS) is a common type of glomerular disease that can lead to chronic renal failure. Various therapeutic regimens have been used in nephrotic FSGS patients. The effect of treatment with prednisolone alone or its combination with azathioprine and cyclosporin and parameters related to a poor outcome are studied. METHODS: Fifty-one patients with idiopathic FSGS and a follow-up period of 5 years were included. Twenty-five were treated with prednisolone alone (1 mg/kg BW/day) or combination of prednisolone (0.5 mg/kg BW/day) with azathioprine (2 mg/kg BW/day) or cyclosporine (3 mg/kg BW/day) in gradually reduced doses whereas 26 patients received no immunosuppressive drugs. Lower prednisolone dose regimens were used as initial treatment in obese, borderline diabetics or patients with bone disease. The clinical course was estimated using the end-points of 50% or doubling of baseline serum creatinine and/or end-stage renal failure. The contribution of clinical and histological parameters in the clinical outcome was estimated by univariate and multivariate analyses. RESULTS: Increase of baseline serum creatinine by 50% during the follow-up period was observed in 2 treated and 9 untreated patients (8% vs. 35%, p = 0.03) whereas doubling of serum creatinine in 2 and 5 patients respectively (8% vs. 19%, p = NS). End-stage renal failure developed in 4 of 51 patients (8%), 2 treated and 2 untreated (p = NS). Parameters related to a poor outcome were baseline serum creatinine and severity of glomerulosclerosis (multivariate analysis OR = 1.08, p = 0.01). Most of patients (68%) who reached end-points had persistent nephrotic syndrome during the follow-up. Remission of nephrotic syndrome was observed more frequently among treated (75 vs. 30.7%, p = 0.05). Prednisolone alone was followed by remission of nephrotic syndrome in 62.5% whereas combination of lower prednisolone dose with azathioprine and cyclosporin in 80 and 85.7% of patients. No serious side-effects were observed. CONCLUSION: This and previous studies suggest that steroid and/or immunosuppressive therapy have a role in amelioration of the clinical course and remission of nephrotic syndrome in patients with FSGS A combination of low predisolone dose with cyclosporine could be used as initial treatment in patients with higher risk for side-effects from the usual prednisolone dose.