Energy balance in haemodialysis and peritoneal dialysis patients assessed by a 7-day weighed food diary and a portable armband device.

BACKGROUND: Energy balance (EB) is important when assessing nutritional status. EB has never been assessed in haemodialysis (HD) and peritoneal dialysis (PD) patients. The present study aimed to assess weekly EB in these patients. METHODS: This clinical cross-sectional study was conducted for 7 days in eight HD and eight PD patients. Nutritional status was assessed by anthropometry, bioelectrical impedance analysis and biochemical markers. Energy intake (EI per day) and total energy expenditure (TEE per day) were determined by a 7-day weighed food diary and a portable armband device, respectively. RESULTS: No significant differences in age, body mass index, fat free mass (FFM), parathyroid hormone were found between the two groups. EB was calculated by subtracting TEE per day from EI per day. EB was negative in HD {-1347 (1276) kJ day(-1) [-322 (305) kcal day(-1) ]}, as well as in PD patients {-427 (5338) kJ day(-1) [-102 (395) kcal day(-1) ]}. TEE per day was positively correlated with EI per day, prealbumin, FFM. EI per day was positively correlated with prealbumin. C-reactive protein was negatively correlated with TEE and FFM (P < 0.05). EB showed a positive correlation with EI per day (P = 0.012) and a negative trend with TEE. CONCLUSIONS: HD and PD patients have a negative EB and are at risk of malnutrition. Inflammatory status determines a lower EI per day and a reduction in TEE per day. The most important parameter in determining EB in HD and PD patients is EI per day. This topic deserves further investigation to better understand the mechanisms of impaired EB with respect to preserving patients' nutritional status.

Upper gastrointestinal symptoms in patients with advanced cancer: relationship to nutritional and performance status.

GOALS OF WORK: The goals of the study were to determine the relationship of upper gastrointestinal symptoms with nutritional status and to assess their association with performance status in patients with advanced cancer. MATERIALS AND METHODS: We studied 143 patients (50 F, 93 M, mean age 68 +/- 11 years, mean body mass index 22.39 +/- 4.3 kg/m(2)). Assessed symptoms were the following: anorexia, nausea, vomiting, dysphagia for solids, dysphagia for liquids, xerostomia, hypogeusia, dysgeusia, hiccup and chewing disturbances. We determined anthropometric parameters, daily energy intake and serum albumin, prealbumin and transferrin. MAIN RESULTS: The most common upper gastrointestinal symptoms were xerostomia (73%), anorexia (49%) and chewing disturbances (40%). Fifty-four percent of patients had weight loss greater than 10%. Seventy-three patients (51%) had daily energy intake lower than their resting energy expenditure. Mean serum prealbumin, albumin and transferrin were below normal range. Mean Eastern Cooperative Oncology Group performance status scale was 3.1 +/- 0.49. Symptoms were often strongly correlated, and usually, patients experienced at least three upper gastrointestinal symptoms at the same time. Anorexia, nausea and vomiting were the symptoms mostly correlated with other symptoms. A correlation was found between vomiting and hiccup. Energy intake (EI) was the nutritional parameter mostly affected by upper gastrointestinal symptoms; moreover, EI is the most predictive factor of upper gastrointestinal symptoms, particularly xerostomia, anorexia and dysphagia for solids. CONCLUSIONS: Upper gastrointestinal symptoms are linked to nutritional parameters: In particular, energy intake represents the most predictive variable of symptom occurrence. The performance status is not affected by upper gastrointestinal symptoms. A rigorous nutritional assessment and the managing of upper gastrointestinal symptoms are crucial in patients with advanced cancer.

Evaluation of nutritional status and dietary intake in patients with advanced cancer on palliative care.

AIM: Cancer cachexia and malnutrition are very common in patients receiving palliative care. They cause a deterioration in the quality of life. METHODS: We studied 144 patients (52 females, 92 males) admitted to our Palliative Care Unit. Anthropometric measurements, food and nutritional intake, and plasma levels of few serum proteins were determined. Basal metabolic rate (BMR) was calculated. RESULTS: A body mass index (BMI) below 18.5 kg/m2 was observed in 23% of females and in 13% of males (P = NS). Twenty females (44%) and 52 males (63%) showed a weight loss of more than 10% over the 6-month period (P = 0.073). Ten females (19%) and 58 males (63%) had an arm muscle area (AMA) below the 5th percentile (P < 0.001), while 20 females (38%) and 21 males (23%) had an arm fat area (AFA) below the 5th percentile (P = 0.071). The daily calorie intake was below the BMR in 22 females (42%) and in 53 males (58%) (P = NS). Plasma levels of prealbumin, transferrin, and albumin were found below the normal range in more than 70% in both sexes. CONCLUSION: Protein energy malnutrition can be easily detected by anthropometric and laboratory indexes. The larger percentage of males with a reduction in lean body mass compared to females could signify an advantage for females since lean body mass is preserved for longer in them. Patients with advanced cancer receiving palliative care should thus be evaluated routinely to assess their nutritional status in order to plan an adequate nutritional program when appropriate.

Trace element levels in adult patients with proteinuria.

AIM: Trace elements are involved in many metabolic processes. They circulate prevalently bound to protein. In literature few studies deal with metal metabolism in adult patients with proteinuria, so we decided to further investigate metal metabolism in proteinuric patients. METHODS: We studied 27 patients (14 male, 13 female), mean age 61.6+/-17 years with different degrees of renal function, serum albumin and proteinuria. Metal concentrations of copper (Cu), zinc (Zn) and aluminum (Al) were measured in serum and urine. No patient had environmental exposure to these metals. RESULTS: The serum Zn level was below the normal range in 11 patients. The serum Cu level was reduced in 5 patients. The Al serum level was elevated in 4 patients. Six patients had reduced and 6 patients had elevated Zn excretion. The urinary Cu excretion was elevated in 6 patients. The urinary Al excretion was elevated in 1 patient. Trace metal concentrations were related neither to renal function nor to total serum protein or albumin levels. Serum zinc was directly correlated with proteinuria and urinary zinc and negatively correlated with testosterone levels in both sexes. CONCLUSION: Adult patients with proteinuria have several modification of trace metal concentration in serum and urine. Serum concentration of metals did not depend on renal function or serum protein levels. Urinary Zn excretion was directly related to proteinuria and serum Zn levels. A negative correlation between serum Zn levels and testosterone was found in both sexes. Renal failure reduced urinary excretion of Cu and Al.

Acid-base balance and respiratory response during biofiltration with polyacrylonitrile membrane.

To further elucidate the mechanisms responsible for the hypoxemia we studied ventilation, pulmonary gas exchanges, blood gas pressures and exchanges of CO2-T, CO2-D and HCO-3 in six patients during AD and BD on 1 m2 cuprophan filter and during BF on 1.2 m2 polyacrylonitrile filter. Blood passing through the dialyzer lost 172.8 mM/h of CO2-T in AD, 149.2 mM/h in BF and gained 25.6 mM/h in BD. In AD VE, VA and PaO2 decreased significantly after 30 and 60 min., in BF for the whole duration of dialysis. PoO2 showed a significant decrease both in AD and BF after 60 min. In AD PaCO2 was significantly reduced after 120 and 180 min. All the above parameters remained unchanged in BD. VCO2 remained unchanged in all. VCO2 and R decreased both in AD and BF. However, when VCO2 was corrected for CO2 loss across the dialyzer, overall CO2 loss (ventilated plus filtered) and R returned to basal values. In AD, HCO-3 and pH fell in the first 120 min., while in BD and BF they increased from the beginning of dialysis. In AD hypoventilation, hypoxemia and inadequate correction of acid-base balance were due to the loss of HCO-3 across the filter. In BF also hypoventilation and hypoxemia were due to the loss of HCO-3 across the filter but the acid-base balance was adequately corrected by HCO-3 reinfusion. In BD, there was HCO-3 gain across the filter which induced a gradual correction of acid-base balance without impairment of ventilation.

[Congenital cystic dilatation of the bile ducts: case report and review of the literature]. / Le dilatazioni cistiche congenite delle vie biliari: case report e revisione della letteratura.

Congenital cysts of the biliary tract are rare anomalies generally observed in pediatric age, exceptionally in adults. The different extension and the morphology of cystic lesions make possible a classification in subtype. This disease, of Len asymptomatic, is characterized by high incidence of complications such as pancreatitis, cholangitis, and cancer. For these reasons, congenital cystic dilatation of bile duct should be radically treated by complete resection of the dilated extraepatic biliary tract. A review of the International Literature and a rare case of congenite dilatation of the intra and extraepatic biliary ducts in a female 54 years old, treated by choledochal resection with hepatico-jejunostomy on Roux en Y segment, are presented.

Percutaneous embolization of periduodenal varix due to portal hypertension in a patient with kidney-pancreas transplantation: a case report.

Kidney-pancreas transplantation is a valid therapeutic option for patients with insulin-dependent diabetes mellitus. However, vascular complications associated with pancreas transplantation are not uncommon. Herein we have reported a 32-year-old woman with a history of insulin-dependent diabetes mellitus and celiac disease. She underwent liver transplantation for acute hepatitis. After 7 years, the patient developed end-stage kidney disease beginning hemodialysis and being listed for a kidney-pancreas transplantation, which was successfully performed when she was 29 years old with enteric diversion (Roux intestinal loop reconstruction). Five years after kidney-pancreas transplantation, she was admitted to our hospital with serious intestinal bleeding and poor liver function. The ultrasound showed a pattern like a arteriovenous fistula near the head of the pancreas. Computed Tomography was not diagnostic; an arteriogram showed the presence of a mesenteric varix and a mesenteric-caval shunt through the duodenum of the pancreatic graft. The liver biopsy and portal pressure gradient showed portal hypertension and liver cirrhosis. To obtain time a waiting a new liver, the patient underwent percutaneous embolization of the mesenteric varix through jugular access. The procedure was uneventful. The patient was successfully transplanted 2 months later. Pancreas function was always satisfactory.

Vascular percutaneous transcatheter embolisation with a new device: Amplatzer vascular plug.

PURPOSE: The aim of this study was to evaluate the effectiveness of the new Amplatzer vascular plug (AVP) for the occlusion of vascular abnormalities and peripheral vessels, especially those with a large diameter. MATERIALS AND METHODS: The new device was used for the occlusion of five internal iliac arteries to prevent retrograde endoleak following endograft repair, three left subclavian arteries for the treatment of type II endoleaks after positioning thoracic aorta stent-grafts, one pulmonary arteriovenous malformation, one haemodialysis fistula in a patient with forearm oedema and one large gastric varix in a patient who had undergone transjugular intrahepatic portosystemic shunt (TIPS) for haemorrhage. RESULTS: The five internal iliac arteries and the three left subclavian arteries were successfully occluded within 8 and 5 min, respectively. The pulmonary arteriovenous fistula was closed within 3 min and percutaneous oxygen saturation rose from 73% to 93%. The haemodialysis fistula was closed with one device within 4 min. The gastric varix was embolised with two AVPs and two coils within 12 min. CONCLUSIONS: The AVP is an effective device for occluding large diameter vascular abnormalities and peripheral vessels. It is inexpensive and enables safe and low-risk embolisation, with saving of time and requiring only low X-ray dose.

A comparative trial of timolol and flutonidin as antihypertensive agents.

In a double-blind cross-over clinical trial, flutonidin (2-4 mg daily) was compared with timolol (20-40 mg daily) in the treatment of mildly or moderately hypertensive patients who concomitantly received fixed diuretic treatment. Each drug was administered for 1 month, with an interval of 2 weeks between the two monthly periods. During administration of flutonidin, blood pressure initially fell but returned to baseline values at the end of treatment. Heart rate was not affected by the drug. Timolol significantly reduced both blood pressure and heart rate. Its effect becomes evident during the 1st week and increases throughout the treatment period. Side effects were more frequent during flutonidin administration than during timolol administration. No significant modifications of the laboratory findings were observed during either flutonidin or timolol treatment.

[Respiratory response and acid-base equilibrium in acetate dialysis and bicarbonate dialysis]. / Réponse respiratoire et équilibre acido-basique au cours de la dialyse à l'acétate et au cours de la dialyse au bicarbonate.

In order to elucidate the mechanisms responsible for the hypoxemia observed during acetate dialysis, but not found during bicarbonate dialysis, the authors studied ventilation, blood gases and their exchanges in the lungs and across the dialyzer on 9 patients. Oxygen consumption was similar both in acetate and bicarbonate dialysis. At the beginning of acetate dialysis, hypocapnia, due to CO2 losses through the dialyzer, causes hypoventilation and hypoxemia; afterwards, the worsening of acidosis (due to bicarbonate losses) stimulates ventilation, thus correcting the initial imbalance. Authors also hypothesize a pulmonary mechanism for CO2 "sparing" contributing to compensate CO2 losses through the dialyzer. The absence of hypoxemia during bicarbonate dialysis would be due to the absence of CO2 losses through the dialyzer.

Pharmacokinetics of ibopamine in patients with renal impairment.

The pharmacokinetics of a single oral dose of ibopamine 100 mg were studied in 15 patients with various degrees of chronic renal impairment (CRI) and in 8 subjects with normal renal function and of comparable age, taken as a control group. Plasma total (mainly conjugated) and free epinine and urinary metabolites (total epinine, HVA and DOPAC) were measured. Both total and free epinine were detectable at the earliest sampling time (15 min) in CRI patients and in normal subjects, thus confirming the promptness of ibopamine absorption. Free epinine pharmacokinetic parameters did not show any appreciable differences among the groups with different degrees of renal impairment, and no statistically significant differences were observed between normal subjects and CRI patients. Progressive renal impairment was associated with higher Cmax, longer t1/2 and larger AUC infinity of total epinine, and with reduced urinary elimination of total epinine and metabolites. Statistically significant differences (p less than 0.01) in Cmax/70 kg, t1/2, and AUC infinity/70 kg of total epinine were found between normal subjects and patients with mild renal impairment. No statistically significant differences were observed in 24-h urinary recoveries of both total epinine and metabolites between normal subjects and patients with mild renal impairment. No adverse effects were experienced during the course of the study. As the kinetics of ibopamine's active moiety, free epinine, were not apparently altered by chronic renal failure, adjustment of its dosage should not be necessary in renal diseases.

Recombinant human erythropoietin reduces free erythrocyte protoporphyrin levels in patients on chronic dialysis.

We studied the significance of free erythrocyte protoporphyrin (FEP) in relation to iron status, aluminum levels and anemia in uremic patients on chronic dialysis. All but 1 patient showed high FEP values closely related to the degree of anemia. Increased FEP levels are due to a defective heme synthesis, not related to iron deficiency or aluminum overload. Treatment of anemia with recombinant human erythropoietin reduced FEP values. We therefore hypothesize that recombinant human erythropoietin ameliorates an enzymatic defect in heme synthesis.

Altered muscle energy metabolism in post-absorptive patients with chronic renal failure.

Skeletal muscle biopsies were performed on 12 healthy sedentary subjects and on 22 non-dyalized chronic renal failure patients (CRF) on a free diet and after overnight fasting. Parathormone, glucagon and insulin were determined at the same time of biopsies. CRF patients showed significantly low ATP and creatine phosphate levels. Regarding enzyme activities, a high hexokinase Vmax was found, while the pyruvate kinase activity was lower than in the control group. For the tricarboxylic acid cycle, citrate synthase, succinate dehydrogenase and malate dehydrogenase activities were higher; total NADH cytochrome c reductase activity was also high, while cytochrome oxidase activity was slightly lower. Both alanine aminotransferase and aspartate aminotransferase activities were considerably high in comparison with the control group. In conclusion, our study revealed a hypermetabolic TCA cycle, but impaired oxidative phosphorylation, which partly explained the reduced ATP concentration. Excessive protein intake and hormonal derangements may play a role in these metabolic changes.