Effect of branched chain amino acid supplementation on dialysis adequacy and nutritional parameters in hemodialysis patients.

Malnutrition in hemodialysis (HD) patients is caused by deficient nutrient and protein intake and has a negative impact on patient outcomes. The assessment of dialysis adequacy in these patients depends to a large extent on the calculation of urea clearance using dialyzer clearance of urea (K) multiplied by the duration of the dialysis treatment (t, in minutes) divided by the volume of distribution of urea in the body (V, in mL); Kt/V. This study aims to detect the effect of branched-chain amino acid (BCAA) supplementation on Kt/V and other nutritional parameters such as serum albumin as well as body mass index. Forty-six patients from the HD Unit of Mostafa Mahmoud Hospital were included in this study. Daily intake of BCAA was continued for three months. At the start of the study, before the intervention, and at the end of the 3rd month, we measured serum albumin, valine, leucine, iso-leucine, and Kt/V. Analysis of data was performed using paired and independent t-test. We found that BCAA has a highly significant effect on increasing the level of albumin, leucine, isoleucine, valine, and Kt/V in HD patients (P <0.001) (Paired t-test). BCAA supplements could be used in this patient population to improve dialysis adequacy and outcome.

Assessment of the relationship between serum paraoxonase activity and epicardial adipose tissue in hemodialysis patients.

PURPOSE: Paraoxonase-1 (PON-1) is a high-density lipoprotein-associated (HDL) enzyme, which has been shown to reduce susceptibility to low-density lipoprotein (LDL) peroxidation. Epicardial adipose tissue (EAT) is a marker of atherosclerosis. The aim of this study was to determine the relationship between PON-1 activity and EAT in hemodialysis (HD) patients. METHODS: This is a cross-sectional study conducted on 72 (43 males) HD patients with end-stage renal disease. Serum levels for lipid profiles, C-reactive protein, calcium, phosphate, and parathyroid hormone were measured. PON-1 activity was also measured and compared to the rate of enzymatic hydrolysis of paraoxon to p-nitrophenol. Echocardiography was used to measure EAT thickness (EATT). The correlation between PON-1 and EATT was assessed, while independent predictors of EATT in HD patients were similarly assessed using multivariate regression analysis. RESULTS: There was a significant low mean value of PON-1 activity in HD patients compared with the control group (82.1 ± 31.6 vs. 164.3 ± 61.5 U/l, p = 0.0001) and significant high mean value of EATT in HD patients, compared with controls (6.2 ± 1.7 vs. 3.9 ± 1.1 mm, p = 0.0001). In addition, there was a significant negative correlation between PON-1 activity and EATT (r = -0.484, p = 0.0001) and a significant positive correlation between PON-1 activity and HDL-C (r = 0.417, p = 0.0003). PON-1, total cholesterol, triglycerides, LDL, HDL, age, and body mass index were found to be independent predictors of EATT. CONCLUSION: Our study demonstrated that PON-1 activity was significantly lower in HD patients compared with healthy controls and that PON-1 activity was inversely correlated with EATT in this population.

The link between bone disease and cardiovascular complications in hemodialysis patients.

INTRODUCTION: The burden on the cardiovascular system is the main cause of mortality in chronic renal patients, and bone disease, which also may cause disability, is one of the most important complications in those patients. The aim of this study was to determine the link between cardiovascular and bone disease, which frequently occur together. METHODS: In this matched case-control study, 70 subjects were subjected for full laboratory assessment as well as estimation of parathyroid hormone (PTH) level, vitamin D level, complete echocardiography, and dual energy absorptiometry. Of the 70 patients, 50 were on regular hemodialysis, and there were 20 normal controls matched with the patients with respect to age and gender. RESULTS: There was a significant decrease in the mean value of serum vitamin D in the hemodialysis patients, i.e., their mean value was 20.47 ± 9.60 whereas the controls had a mean value of 37.15 ± 7.67. Thus, there was a highly-significant, negative correlation between vitamin D and left ventricular mass (LVM) in the patients. We found that there was a highly-significant increase in the mean PTH levels of the patients (820.22 ± 393.51), whereas it was 57.60 ± 13.72 for the controls. The statistical significance was less than 0.001, a highly-significant increase in the mean of the T score levels in the patients (-2.15 ± 2.56), whereas it was -0.47 ± 0.71 for the controls with a statistical significance of less than 0.001. There also was a highly-significant correlation between the T score and LVM. CONCLUSION: A significant correlation was found between bone disease and the occurrence of a left ventricular mass. We recommend early strict correction of the serum levels of vitamin D, PTH, calcium, and phosphorus.

Association between serum visfatin and carotid atherosclerosis in diabetic and non-diabetic patients on maintenance hemodialysis.

INTRODUCTION: Adipose tissue releases bioactive factors termed adipokines. Visfatin is an adipokine that plays an active role promoting vascular inflammation and atherosclerosis. The purpose of this study was to determine the association between serum visfatin levels and carotid atherosclerosis in diabetic and non-diabetic patients on maintenance hemodialysis (HD) in order to clarify the role of serum visfatinas, a risk factor for cardiovascular complications in HD patients. METHODS: Forty patients on maintenance hemodialysis were enrolled in this case-control study in 2015. They were subdivided into two groups, i.e., a diabetic group (n = 20) and a non-diabetic group (n = 20). Twenty healthy subjects who were age and gender matched were included as a control group. Carotid Duplex studies were performed on all patients, and serum visfatin was determined by a competitive enzyme immunoassay. RESULTS: HD patients showed a highly significant increase in serum visfatin, urea, creatinine, Ca×Ph, K, fasting glucose, triglycerides, LDL levels, and a significant decrease in eGFR, Na, HDL, and Hb compared to the control group. Also, serum visfatin levels showed a highly significant increase in the diabetic HD group compared to both the non-diabetic HD and control groups. Serum visfatin showed a highly significant increase in non-diabetic HD patients compared to the control group. Carotid intima-media thickness (IMT) showed a highly significant increase in HD group compared to the control group. Serum visfatin correlated positively with serum urea, creatinine, glucose, and IMT, but it was negatively correlated with eGFR, Na, and HDL. CONCLUSION: We concluded that serum visfatin is increased in HD patients with and without diabetes. Moreover, its association with IMT may be involved in the pathogenesis of atherosclerosis in CRF patients.

Role of alteration in Treg/Th17 cells' balance in nephropathic patients with Type 2 diabetes mellitus.

INTRODUCTION: In type 2 diabetes mellitus, the adaptive immune system drives systemic inflammation, promoting insulin resistance and related complications, such as diabetic nephropathy. Increased infiltration of activated T lymphocytes has been found in patients with diabetic nephropathy. T-cell influx and accumulation are the factors that aggravate diabetic nephropathy and link with glomerular filtration surface and albumin excretion. An appropriate balance between pro-inflammatory (T helper 17: Th17, and T helper 1: Th1) and anti-inflammatory (regulatory T cells: Tregs) subsets of T cells is critical to maintain homeostasis and avoid inflammatory disease. The aim of this study was to determine the balance between T helper 17 and regulatory T cells in type 2 diabetic patients who have diabetic nephropathy. METHODS: This case control study was conducted between December 2013 and June 2014 in Theodor Bilharz Research Institute in Egypt. Forty patients and 20 healthy volunteers were recruited in the study, and three groups were formed, i.e. two groups of cases with 20 patients in each group and one group of 20 controls) The groups were 1) 20 type 2 diabetic patients with nephropathy (group A); 2) 20 type 2 diabetic patients without nephropathy (group B); and 3) 20 healthy individuals (control group). Evaluation of T cells was done by standard 2-color flow cytometry. RESULTS: The study found higher mean of Th17 counts and Th17/Treg ratio among type 2 diabetic nephropathy patients compared to other groups; but a lower mean of Treg count was identified among type 2 diabetic nephropathy patients than in the other groups (p-value = 0.001). CONCLUSION: The important role for regulatory T cells in the protection against nephropathy in type 2 diabetic patients was demonstrated, and also it was observed that T helper 17 cells were associated with renal affection.

Occult Hepatitis C Virus Infection in Hemodialysis Patients; Single Center Study.

INTRODUCTION: A new form of hepatitis C virus infection, known as occult hepatitis C virus (HCV) infection, is characterized by the presence of HCV_RNA in the liver or peripheral blood mononuclear cells (PBMCs). However, no serological markers of infection occur and there is not as much damage to the liver damage as is produced by chronic hepatitis C. There is a high incidence of HCV infection among hemodialysis patients, there is significant concern about viral transmission. HCV infection is a major problem in hemodialysis (HD) units even though blood products are screened for anti-HCV antibodies and other precautions are taken. The aim of this study was to determine the prevalence of occult HCV infection in PBMC in chronic hemodialysis (CHD) patients in the dialysis unit at Theodor Bilharz Research Institute (TBRI) with HCV antibodies and HCV RNA negativity irrespective of their liver function tests. METHODS: Fifty-three patients who were repeatedly were anti-HCV negative and serum HCV-RNA negative and on regular hemodialysis for > six months were enrolled in the study, which was conducted in the dialysis unit of Nephrology Department at TBRI; there were 10 healthy matched controls. The patients were classified into two groups according to the result HCV RNA in their PBMCs. Serological markers of HCV infection, including anti-HCV antibody and serum HCV-RNA, were repeatedly negative for all patients included in the study. We collected serum and PBMC samples from the patients on the day they entered the study. The test of all serum samples for anti-HCV antibodies and HCV-RNA was repeated by RT-PCR to ensure that the patients did not have these HCV serologic markers, We also measured their ALT and GGT levels. RESULTS: Occult hepatitis C virus infection (OCI) was detected in 15.1% of our CHD patients without any evidence of chronic liver disease. CONCLUSION: Occult HCV infection was present among the hemodialysis patients irrespective of whether they had persistent abnormal values of liver enzymes for which no cause had been identified. Further study is required to determine the clinical significance of occult HCV infections in these patients.