Association of Neutrophil-to-Lymphocyte Ratio With Inflammation and Erythropoietin Resistance in Chronic Dialysis Patients.

BACKGROUND: Neutrophil-to-lymphocyte ratio (NLR) was widely studied as a prognostic marker in various medical and surgical specialties, but its significance in nephrology is not yet established. OBJECTIVE: We evaluated its accuracy as an inflammation biomarker in a dialysis population. DESIGN SETTING: Single-center retrospective study. PATIENTS: The records of all 550 patients who were treated with hemodialysis (HD) or peritoneal dialysis (PD) from September 2008 to March 2011 were included. MEASUREMENTS: NLR was calculated from the monthly complete blood count. METHODS: Association between NLR and markers of inflammation (C-reactive protein [CRP], serum albumin, and erythropoietin resistance index [ERI]) was measured using Spearman coefficient. RESULTS: In total, 120 patients were eligible for the correlation analyses. We found a positive correlation between NLR and CRP (all patients: r = 0.45, P < .001; HD: r = 0.47, P < .001; PD: r = 0.48, P = .13). NLR and albumin were inversely correlated (r = -0.51, P < .001). Finally, high NLR was associated with a nonsignificant increased ERI, but we have not demonstrated a direct correlation. LIMITATIONS: CRP and albumin are not measured routinely and were ordered for a specific clinical reason leading to an indication bias. Also, no relationship with clinical outcome was established. CONCLUSIONS: NLR seems to be a good inflammatory biomarker in dialysis in addition to being easily available. However, controlled studies should be conducted to properly assess and validate NLR levels that would be clinically significant and relevant, as well as its prognostic significance and utility in a clinical setting.

CONTEXTE: La qualité de marqueur pronostique du ratio neutrophiles/lymphocytes a fait l'objet d'études approfondies dans plusieurs disciplines médicales et spécialités chirurgicales. En revanche, son importance n'est toujours pas établie dans le domaine de la néphrologie. OBJECTIF DE L'ÉTUDE: Nous avons voulu évaluer l'efficacité du ratio neutrophiles/lymphocytes comme biomarqueur de l'inflammation chez une population de patients dialysés. MODÈLE DE L'ÉTUDE: Il s'agit d'une étude rétrospective restreinte à un seul établissement. PARTICIPANTS: Les dossiers médicaux des 550 patients ayant été traités par hémodialyse (HD) ou par dialyse péritonéale (DP) entre septembre 2008 et mars 2011 ont été retenus pour cette étude. MESURES: Le ratio neutrophiles/lymphocytes a été calculé à partir de la formule sanguine complète prélevée mensuellement. MÉTHODOLOGIE: On a utilisé le coefficient de Spearman pour mesurer la corrélation entre le ratio neutrophiles/lymphocytes et certains marqueurs de l'inflammation : la protéine C-réactive, l'albumine sérique et l'index de résistance à l'érythropoïétine (IRE). RÉSULTATS: De tous les dossiers médicaux retenus, seuls 120 patients étaient admissibles à l'analyse de corrélation. Nous avons pu établir une corrélation positive entre le ratio neutrophiles/lymphocytes et la protéine C-réactive (r=0,45; p<0,001 pour l'ensemble des patients, r=0,47; p<0,001 chez les patients en HD, et r=0,48; p=0,13 chez les patients sous DP), alors que la corrélation était inversée dans le cas de l'albumine sérique (r=0,51; p<0,001). Nous avons également observé qu'un ratio neutrophiles/lymphocytes élevé était associé à une élévation non significative de l'IRE, sans toutefois établir une corrélation directe. LIMITES DE L'ÉTUDE: Règle générale, l'albumine sérique et la protéine C-réactive ne sont mesurées que lorsqu'une raison d'ordre clinique le demande, ce qui pourrait signaler un biais. De plus, aucun lien n'a été établi entre le ratio neutrophiles/lymphocytes et les devenirs cliniques des patients. CONCLUSION: Le calcul du ratio neutrophiles/lymphocytes semble être un bon indicateur de l'état inflammatoire chez les patients dialysés. Qui plus est, les données nécessaires pour évaluer ce ratio sont faciles à obtenir. Néanmoins, des études contrôlées devraient être menées pour déterminer les valeurs de ratio neutrophiles/lymphocytes qui seraient significatives du point de vue clinique, de même que pour établir l'importance du ratio neutrophiles/lymphocytes sur le plan du pronostic et sa pertinence dans un cadre clinique.

Conversion of oral alfacalcidol to oral calcitriol in the treatment of secondary hyperparathyroidism in chronic hemodialysis patients.

PURPOSE: The optimal vitamin D3 therapy for the treatment of secondary hyperparathyroidism (SHPT) in chronic hemodialysis patients is still controversial. Recent studies suggest that uremia in end-stage renal disease is associated with enzymatic hepatic dysfunction altering 25-hydroxylation of vitamin D3. The goal of our study was to compare the efficacy of calcitriol, the fully hydroxylated active form of vitamin D3, to alfacalcidol which needs 25-hydroxylation to be effective, for the treatment of SHPT in chronic hemodialysis patients. METHODS: We retrospectively reviewed 45 chronic hemodialysis patients who were switched from oral alfacalcidol to oral calcitriol for the treatment of SHPT. Parathyroid hormone (PTH), serum calcium and serum phosphorus levels were compared pre- and post-conversion using paired Student's t tests. RESULTS: The mean dose of active vitamin D3 decreased from 3.50 mcg/week at baseline to 2.86 mcg (P < 0001) after the switch from alfacalcidol to calcitriol. PTH significantly decreased from 94.4 to 82.6 pmol/L (-11.8 pmol/L, P = 0.02). The mean corrected calcium increased from 2.17 to 2.25 mmol/L (+0.08 mmol/L, P < 0.001) without any clinically significant hypercalcemia, and phosphorus levels were stable. Results were similar in a subgroup of patients (n = 17) for whom the medication was administrated during the hemodialysis session, ensuring a complete compliance. CONCLUSIONS: According to our study, calcitriol in equal dosage is more effective than alfacalcidol in lowering serum PTH level in chronic hemodialysis patients. This suggests that calcitriol may be the optimal active vitamin D3 for the treatment of SHPT in chronic hemodialysis patients.

Retrospective Study Looking at Cinacalcet in the Management of Hyperparathyroidism after Kidney Transplantation.

Objectives. The primary objective of this study is to evaluate the use of cinacalcet in the management of hyperparathyroidism in kidney transplant recipients. The secondary objective is to identify baseline factors that predict cinacalcet use after transplantation. Methods. In this single-center retrospective study, we conducted a chart review of all patients having been transplanted from 2003 to 2012 and having received cinacalcet up to kidney transplantation and/or thereafter. Results. Twenty-seven patients were included with a mean follow-up of 2.9 ± 2.4 years. Twenty-one were already taking cinacalcet at the time of transplantation. Cinacalcet was stopped within the first month in 12 of these patients of which 7 had to restart therapy. The main reason for restarting cinacalcet was hypercalcemia. Length of treatment was 23 ± 26 months. There were only 3 cases of mild hypocalcemia. There was no statistically significant association between baseline factors and cinacalcet status a year later. Conclusions. Discontinuing cinacalcet within the first month of kidney transplantation often leads to hypercalcemia. Cinacalcet appears to be an effective treatment of hypercalcemic hyperparathyroidism in kidney transplant recipients. Further studies are needed to evaluate safety and long-term benefits.

Retroperitoneal fibrosis: retrospective descriptive study on clinical features and management.

INTRODUCTION: Retroperitoneal fibrosis (RPF) is a rare condition characterized by the presence of inflammatory and fibrous retroperitoneal tissue that often encases the ureters or abdominal organs. This study describes the clinical characteristics, diagnostic methods, and treatments and their effects on renal function. METHODS: We conducted a retrospective analysis of patients diagnosed with RPF at Maisonneuve-Rosemont Hospital. RESULTS: We identified 17 patients with RPF between 1998 and 2013. Eight patients were females (47%), and the mean age was 62±18 years. Eleven patients were idiopathic. Back pain was the most common symptom. All diagnoses were made based on the finding of a retroperitoneal mass on the computed tomography scan. Three patients had histological diagnosis of RPF and seven patients had unspecific changes on their biopsy. Twelve patients needed double-J stents, three patients had a temporary percutaneous nephrostomy, two patients had to have a nephrectomy for refractory ureteral obstruction, and one patient required hemodialysis. Ten patients with idiopathic RPF received medical treatment. In the treated group, only two patients had complete remission of the disease and five patients had improvement of their lesions. There were no deteriorations and only one relapse. Seven patients did not receive any treatment; two of them achieved complete remission, one of them deteriorated, and two of them had no changes. CONCLUSION: Most of our cases of RPF were idiopathic. Almost all treated patients received prednisone and seemed to respond, at least partially. There was a lot of heterogeneity in patient management, which makes it difficult to compare treatment effects. However, treated patients seemed to have more favorable outcomes than those who were not.

The effect of lanthanum carbonate on metabolic acidosis in patients with chronic kidney disease stage IV, V and V-D.

PURPOSE: Hyperphosphatemia and metabolic acidosis are frequently encountered in advanced chronic kidney disease (CKD) patients. Correction of metabolic acidosis in patients with advanced CKD leads to a decrease in the progression of renal impairment and improves nutritional outcomes. Lanthanum carbonate is used for control of hyperphosphatemia. This study evaluated the effect of lanthanum carbonate on metabolic acidosis in CKD IV-V patients and in patients on dialysis. METHODS: Retrospective data of patients in whom lanthanum carbonate therapy was initiated were collected from 2009 to 2013 in a single dialysis center. Of the 79 patients in whom lanthanum carbonate was introduced, 51 patients were included in the analysis. Of the 51 patients, 39 patients received chronic hemodialysis, two patients received peritoneal dialysis therapy, and 10 patients had stage IV-V CKD not on dialysis. The primary outcome was the serum bicarbonate change after the introduction of lanthanum carbonate. RESULTS: There was a significant increase in mean serum bicarbonate concentration of 2.79 mmol/L (p ≤ 0.001) compared to baseline. The increase remained in the CKD IV-V patients (2.50 mmol/L, p = 0.005) and in the patients on dialysis (2.81 mmol/L, p < 0.001). Serum bicarbonate remained higher (p > 0.05) than baseline up to 6 months after lanthanum carbonate introduction. CONCLUSION: In this study, lanthanum carbonate introduction increased serum bicarbonate concentration in a small sample of CKD IV-V patients and in patients on dialysis. Further studies are needed to confirm this effect and investigate whether the correction of metabolic acidosis by using lanthanum carbonate in CKD IV-V patients can improve clinical outcomes.