Potassium binders in hemodialysis patients: a friend or foe?

There is insufficient evidence on the utility of potassium-binding resins in patients with end-stage renal disease on dialysis. In addition, their poor tolerability raises concerns of patient adherence. We aimed to assess the efficacy of calcium resonium and investigate the impact of counseling on adherence pattern as well as treatment response. Adult patients on hemodialysis receiving calcium resonium were enrolled with a control group not on treatment. Adherence patterns and adverse effects were recorded following patient interviews. Patients were stratified into 28 adherent (A), 42 non-adherent (NA), and 30 controls (C). Patient education was undertaken, and serum potassium levels were evaluated for 3 months pre- and post-counseling with inter- and intra-group comparison. A statistically significant difference was observed between potassium levels at baseline in A and NA groups but not post-education, which was related to worsening control in former and not due to improvement in NA patients. The poor effectiveness of calcium resonium in the control of hyperkalemia was likely related to non-compliance due to gastrointestinal (GI) intolerability. Dietary indiscretions as well as lack of consistent use of cathartics may have also contributed. No difference in dialysis adequacy was noted among groups, although the contribution of residual renal function was not assessed. These findings raise concern regarding cost-efficacy of this medication and lend credence to investing in traditional measures in hyperkalemia management, namely dietary compliance and adequate dialysis. Further long-term trials are awaited to better define the role of calcium resonium in the dialysis setting.

Development of Novel Eating Error Scoring Tool to Evaluate Adult Eating Behavior Anomalies Among the United Arab Emirates Population.

Introduction Maladaptive eating behaviors are emerging as the most significant determinants of obesity with a promising role in intervention. In the absence of a standardized tool to assess eating variations, an Eating Error Score (EES) tool was devised which comprised five zones for evaluating the severity of obesogenic behaviors as well as the specific area(s) with the highest susceptibility. This pilot study was aimed at evaluating the effectiveness of the EES in quantitating the eating behavior errors associated with excess weight and identifying the most affected zones. Methods The EES questionnaire was designed to explore potential disturbances in five zones of eating behavior related to the impetus to eat (Munger), meal choices and attentiveness to cravings (Impulsive), consumption speed (Speed feeding), cues to stop ingestion (Indulgent) and the social aspect of eating (Relationship). The questionnaire was conducted on adults with varying body mass index (BMI) attending governmental outpatient clinics. The correlation between EES and BMI was determined through Pearson Coefficient. Results A total of 204 participants completed the EES questionnaire. There were 72 males and 132 females with a mean BMI of 27.63 ± 6.16 kg/m2 and with nearly equal distribution between normal weight (37.2%), overweight (32.4%), and obese (29.4%) individuals. Nearly 75% of our cohort had a moderate total EES, and the remainder was equally distributed between the mild and severe ranges. A weak but significant correlation was observed between total EES and BMI (r=0.275, p<0.001) suggesting increasing obesogenic styles in participants with excess weight. In addition, a similar weak but significant correlation was noted between Body Mass Index and the Munger and Impulsive zones (r=0.266 and 0.258 and p<0.001, respectively) suggesting more severe maladaptive eating behaviors in these areas. No correlation was found with the Speed feeding, Indulgent, and Relationship zones. Conclusion The EES may be a useful tool for assessing the extent of maladaptive eating behaviors, which predispose individuals to weight gain and sabotage their weight loss efforts. Undoubtedly, the utility of the tool needs to be corroborated in large population studies. Further, identifying the specific operant zones may show promise as many of these habits are potentially modifiable and can be targeted for weight control, most notably those associated with the Munger and Impulsive zones.

Adolescent eating behaviors in the UAE: Time to intervene.

BACKGROUND: Obesity is the single most burdensome lifestyle disease, which has reached epidemic proportions. This study aimed to examine the eating behavior patterns and beliefs in a group of adolescents living in the United Arab Emirates (UAE). PROCEDURE: A questionnaire was administered to adolescents (aged 11 and 18 years) attending outpatients' clinics at governmental health facilities. Informed consent was obtained, and the questionnaire was available in English or Arabic languages. RESULTS: In all, 36 adolescent subjects participated in our study with 12 males and 24 females. UAE nationals constituted 72% of our participants and 28% were of other ethnic backgrounds; 75% were overweight to obese with 17% normal and 8% underweight. The majority of patients were healthy with only 6 patients suffering chronic medical diseases. We uncovered that in less than half of our cohort, the decision to eat came directly from the individuals themselves, but it was more influenced by their families. Food consumption was largely in response to physical hunger with the sensation perceived in the upper abdomen by one-third and the remainder localizing it to various other areas. Excessive caloric intake with frequent meals and snacks was also reported. Our study subjects decided what to consume mainly based on what appeared appetizing, followed by availability and cravings and to a lesser extent based on health recommendations. Excessive speed of food ingestion was self-reported in the majority of participants. Moreover, almost half of the adolescents were unable to turn down food offerings from their close family members and over one-fourth were unable to refuse food from other persons. Common symptoms reported included dysphoric mood, disordered sleep, decreased energy and concentration difficulties as well as low self-esteem. CONCLUSION: Our study uncovered certain eating behaviors in the cohort of adolescents, which may be important in promoting weight gain. These included misconceived hunger signals, excessive frequency, amount and speed of food consumption as well as more focus on food taste, inattentiveness to cravings and a strong social influence on food intake decisions. The findings of our study aim to shed some light on the eating patterns among adolescents and encourage research to investigate eating behaviors on an expanded scale evaluating ethnic, gender and age-related differences.

Get lean and go green: Role for "Eat-ology" behavior modification.

Obesity rates are rising exponentially reaching global epidemic proportions and are associated with substantially increased morbidity and mortality. Less appreciated are the serious risks this poses on our environment from increased greenhouse gas emissions related to obesogenic behavior. In spite of a plethora of diets, the results are short term and nonsustainable, thereby leaving individuals battling with more weight than they lost. This is likely attributable to inherent flaws in the nature of weight loss diets or perhaps the approach of implementing them. These grim realities will be exposed to lead the way to uncover a novel "behavior modification for weight loss" strategy called Eat-ology. It exposes eating errors and imparts techniques to transform them into eating essentials, thereby enabling weight loss and its long-term maintenance. It is through such approaches that we can hope to win the fight against obesity and achieve not only a leaner global society but also a greener environment.

Potential benefits of controlling coronary heart disease risk factors in the United Arab Emirates.

BACKGROUND: Cardiovascular risk factors including obesity, diabetes, hypertension, and dyslipidemia, are highly prevalent in the United Arab Emirates. In spite of significant awareness initiatives, little is known about the potential benefits of controlling these risk factors. AIMS: To assess the prevalence of preventable risk factors for coronary heart disease (CHD), and the likely benefits of controlling these risk factors. METHODS: In a health survey stratified by self-reported hypertension, we enrolled 349 hypertensive and 641 normotensive subjects of diverse ethnicity in Al-Ain city, and measured CHD risk factors. We used the Framingham risk score to estimate the proportion of CHD potentially preventable by controlling hypertension, dyslipidemia, diabetes mellitus (DM), and smoking. RESULTS: Smoking was similar in the two groups (hypertensives 13.2% vs. normotensives 14.2%). The prevalence of diabetes, dyslipidemia [mean (SD) triglycerides, high-density lipoprotein-cholesterol (HDL-C)], overweight/obesity, and thus the 10-year Framingham risk were all significantly (p < 0.001) higher among hypertensive than normotensives. CONCLUSION: Prevention of type 2 DM, aggressive control of hypertension and dyslipidemia, and smoking cessation could potentially reduce the 10-year incidence of CHD. Barriers include lack of awareness of this problem among the general population and health care providers.

Under- treatment and under diagnosis of hypertension: a serious problem in the United Arab Emirates.

BACKGROUND: Hypertension, notably untreated or uncontrolled, is a major risk factor for cardiovascular diseases (CVD) morbidity and mortality. In countries in transition, little is known about the epidemiology of hypertension, and its biochemical correlates. This study was carried out in Al Ain, United Arab Emirates, to characterize self-reported (SR) normotensives and hypertensives in terms of actual hypertension status, demographic variables, CVD risk factors, treatment, and sequalae. METHODS: A sample, stratified by SR hypertensive status, of 349 SR hypertensives (Mean age +/- SD; 50.8 +/- 9.2 yrs; Male: 226) and 640 SR normotensives (42.9 +/- 9.3 yrs, Male: 444) among nationals and expatriates was used. Hypertensives and normotensive subjects were recruited from various outpatient clinics and government organizations in Al-Ain city, United Arab Emirates (UAE) respectively. Anthropometric and demographic variables were measured by conventional methods. RESULTS: Both under-diagnosis of hypertension (33%) and under-treatment (76%) were common. Characteristics of undiagnosed hypertensives were intermediate between normotensives and SR hypertensives. Under-diagnosis of hypertension was more common among foreigners than among nationals. Risk factors for CVD were more prevalent among SR hypertensives. Obesity, lack of exercise and smoking were found as major risk factors for CVD among hypertensives in this population. CONCLUSION: Hypertension, even severe, is commonly under-diagnosed and under-treated in the UAE. Preventive strategies, better diagnosis and proper treatment compliance should be emphasized to reduce incidence of CVD in this population.

Gulf Cooperation Council-dialysis outcomes and practice patterns study: An overview of anemia management trends at the regional and country specific levels in the Gulf Cooperation Council countries.

The Gulf Cooperation Council-Dialysis Outcomes and Practice Patterns Study (GCC-DOPPS) marks the joining of the six Gulf region countries including Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates to the main DOPPS study in 2012. The current review is a descriptive reporting on results related to the management of anemia from these countries. Our data demonstrate consistent anemia management patterns across the GCC countries allowing the achievement of international treatment levels. Overall, the majority of hemodialysis patients were prescribed appropriate erythropoiesis-stimulating agents (ESAs) and supplemental iron, enabling the attainment of mean hemoglobin (Hb) level of 10.9 g/dL. Comparisons of the individual country profiles reveal individual differences in the choice and mode of ESA and iron administration. However, all countries displayed good compliance with guideline recommendations. The same challenges as elsewhere are faced in the GCC, with respect to optimizing Hb levels and judiciously using ESA and iron supplements. Some opportunities exist for focused efforts to fine tune inter-facility variability in anemia management based on continued data tracking. The latter is vital in enabling adopting new trends to further improve not only anemia management but also the wholesome care of dialysis patients.

Plasma BNP in patients on maintenance haemodialysis: a guide to management?

The number of patients requiring long-term haemodialysis is increasing throughout the world. Cardiovascular disease is much more common in these patients than in the general population and accounts for the majority of deaths. New approaches to management are clearly needed to reduce this excessive cardiovascular burden. We propose that circulating levels of the cardiac natriuretic peptides, B-type natriuretic peptide (BNP) in particular, might provide a useful, objective guide to the management of their hydration status and pharmacotherapy. An overview of the literature shows that plasma levels of the cardiac natriuretic peptides are increased in this patient population and reflect cardiac preload and afterload along with cardiac pathology, thereby providing an index of cardiovascular (especially cardiac) stress and distress. Circulating levels of the cardiac peptides change in parallel with cardiac load, especially across haemodialysis. Furthermore, there is robust evidence that natriuretic peptide levels are predictive of cardiovascular outcome in these patients. Accordingly, we hypothesize that management of their haemodialysis, and pharmacotherapy designed specifically to lower plasma BNP levels to, or close to, the normal range, will reduce the excessive burden on the cardiovascular system and thereby ultimately lower the incidence of cardiovascular disease. We outline, in broad terms, how a trial to test this hypothesis might be designed.

Epidemiology and referral patterns of patients with chronic kidney disease in the Emirate of Abu Dhabi.

According to estimates, the dialysis prevalence in Abu Dhabi is around 370 per million population. The annual growth is 12-15% and the dialysis population is likely to double in the next five years. Most patients present to dialysis as an emergency and only 2.7% have an arteriovenous fistula at the first dialysis. The prevalence of chronic kidney disease (CKD) in the Emirate is undefined. A study of the epidemiology of CKD and referral patterns was undertaken. SEHA, the Abu Dhabi Health Service delivery company, has a unified computer system containing all measurements made in its laboratories. This study considered all serum creatinine measurements performed between 1 September 2011 and 31 October 2012 from outpatient departments or emergency rooms. The estimated glomerular filtration rate (eGRF) was calculated using the Modification of Diet in Renal Disease formula (the Schwartz formula was used for children). We identified 331,360 samples from 212,314 individuals. The mean serum creatinine was 61 ± 48 µmol/L in females (59 ± 43 µmol/L in Emiratis, 63 ± 54 µmol/L in expatriates) and 87 ± 69 µmol/L in males (80 ± 59 µmol/L in Emiratis, 92 ± 74 µmol/L in expatriates). Among Emiratis, 4.6% of males and 2.8% of females had an eGFR between CKD 3 and 5. Among expatriates, 4.2% of males and 3.2% of females had an eGFR between CKD 3 and 5. On average, eight months elapsed before a patient with CKD 3, and three months for a patient in CKD 5, to attend the nephrology clinic. This study has defined the prevalence of CKD within Abu Dhabi and demonstrated the need to improve identification and referral of CKD patients. Possible solutions include campaigns to increase public and physician awareness of CKD.

A prospective randomized pilot study on intermittent post-dialysis dosing of cinacalcet.

BACKGROUND: Treatment of secondary hyperparathyroidism (SHPT) is important in management of patients with end-stage renal disease on hemodialysis (HD). Calcimimetic agent, cinacalcet provides an option for control of SHPT in patients who fail traditional therapy. It may not have optimal results in non-compliant patients. To enhance compliance, we evaluated effectiveness of post-dialysis dosing of cinacalcet (group AD) as compared to daily home administration (group D) in a prospective randomized trial of HD patients with refractory SHPT. METHODS: After 2-week run-in phase, patients were randomly assigned to two treatment groups. In group AD (N = 12), patients were administered cinacalcet on the day of dialysis (3 times/week) by dialysis staff, while in control group D (N = 11), cinacalcet was prescribed daily to be taken by patients at home. Intact parathyroid hormone (i-PTH), serum calcium, phosphorus, and alkaline phosphatase were followed for 16 weeks and compared to baseline in both groups. Data were analyzed using between-groups linear regression for repeated measures. RESULTS: No significant decline in i-PTH occurred in group AD at 16 weeks as compared to a significant drop in group D (p = 0.006). However, subgroup analysis showed effectiveness of post-dialysis dosing in patients with less severe SHPT (p = 0.04). CONCLUSION: Although daily dosing overall was more effective for treatment of SHPT, dialysis dosing was effective in patients with less severe SHPT. This warrants a larger study considering the limitations of this pilot trial. In the meantime, dialysis dosing can be considered in non-compliant patients with less severe SHPT.

Comparison between short- and long-acting erythropoiesis-stimulating agents in hemodialysis patients: target hemoglobin, variability, and outcome.

PURPOSE: Maintaining target hemoglobin (Hb) with minimal variability is a challenge in hemodialysis (HD) patients. The aim of this study is to compare the long- and short-acting erythropoietin-stimulating agents such as Aranesp and Eprex in achieving these targets. METHODS: Randomized, prospective, open-labeled study of 24 weeks includes stable patients on HD >3 months, age >18 years, and on Eprex for >3 months. Patients were randomized into two groups: A-(Aranesp group):HD patients on Eprex Q TIW or BIW were converted to Aranesp Q weekly, by using the conversion factor of 200:1 and those on Eprex Q weekly to Aranesp Q 2 weeks; B-(Eprex group):patients continued on Eprex treatment. Hemoglobin target was set at (105-125 g/l). Primary end points were percentage of patients achieving target Hb, hemoglobin variability, and number of dose changes in each group. RESULTS: This study consisted of 139 HD patients: 72 in the Aranesp and 67 in the Eprex-mean (SD) age 54 (16.2) years, 77 (55 %) males. About 46 % were diabetic. Target Hb achieved in 64.8 % of the Aranesp and 59.7 % in the Eprex (p = 0.006). Hb variability was less frequent in the Aranesp group (p = 0.2). Mean number of dose changes was 1.3 (0.87) in the Aranesp and 1.9 (1.2) in the Eprex (p < 0.001). There was 1 vascular access thrombosis in the Aranesp and 8 in the Eprex (p < 0.001). There was no difference in hospitalization and death number between the 2 groups. CONCLUSIONS: Aranesp Q weekly or every 2 weeks is more efficient in achieving target Hb, with less dose changes and minor vascular access complications.

Encapsulating peritoneal sclerosis: a rare complication of peritoneal dialysis in Al-ain, United arab emirates.

Encapsulating peritoneal sclerosis (EPS) is a rare complication of peritoneal dialysis (PD) with devastating consequences. Although it can occur among patients on PD, it may present long after PD has been discontinued; thus, its diagnosis depends on a high index of suspicion. We present a rare case of EPS in the United Arab Emirates with a protracted course and delays in recognizing the condition until after resolution of the acute attack. This case highlights the need for early identification of risk factors as well as the subtle features of EPS for appropriate diagnosis and perhaps even prevention; this being worth a ton of cure. A review of the literature including the latest evidence-based treatment options is also highlighted.

GFR estimation in the morbidly obese pre- and postbariatric surgery: one size does not fit all.

BACKGROUND: Glomerular hyperfiltration commonly associated with obesity is expected to improve postbariatric surgery. However, formula-based glomerular filtration rate (GFR) estimation in these patients is limited by body size confounders necessitating use of modified equations, the reliability of which remains uncertain. METHODS: In this study, various GFR-estimating formulae were compared in morbidly obese patients at baseline and postbariatric surgery. Through a retrospective chart review, we identified 220 patients who had undergone this procedure, with over 6-month follow-up, during which major weight reduction was achieved. RESULTS: A significant decrease in BP and glomerular hyperfiltration was observed, though there was large variability in GFR estimation using the different formulae. Gross over and underestimation was observed which improved with correction for body size confounders especially lean body weight (LBW). Postoperatively, significant attenuation in estimated GFR was demonstrated when LBW or body surface area-adjusted versions were used. In a subgroup of patients with chronic kidney disease, a significant improvement in GFR was seen postoperatively with the LBW-modified formula but there were again inconsistencies when using other equations. CONCLUSION: Though clinicians must be critical in the application of GFR estimates to patient care, LBW adjustment appears to be the most practical solution to its estimation in the obese patients. This is particularly true for patients with normal renal function but appears to be also applicable to those with compromised kidney function. Future studies are needed to compare these equations with a gold standard GFR measure as well as to explore whether the renal benefits from bariatric surgery are sustained or seen in more advanced CKD stages.

Renal variant of Fabry disease with sporadic GLA gene mutation: role of early renal biopsy.

Fabry disease (FD) is a rare, X-linked inherited disease of glycosphingolipid metabolism due to deficiency of lysosomal α-galactosidase A activity. Scarce activity of lysosomal α-galactosidase A results in progressive accumulation of globotriaosylceramide (Gb3) within lysosomes, believed to trigger a flow of cellular changes that lead to the clinical manifestation of the disease. We present a 23-year-old male with renal variant of FD who was born from non-affected parents, which, to the best of our knowledge, has not been reported in the literature so far. In conclusion, FD can occur due to sporadic GLA gene mutation. Pure renal involvement might be associated with progressive disease which leads to end-stage renal disease within a short period. Physicians should have a high index of suspicion for FD especially in male cases with unexplained renal failure that are slowly progressive in nature, even in the absence of a clear hereditary component. Early renal biopsy is recommended in any progressive renal impairment.

Renal biomarkers for assessment of kidney function in renal transplant recipients: how do they compare?

Accurate assessment of renal function is of key importance, given its prognostic value. However, gold standard measures are cumbersome, and serum creatinine itself is an insensitive predictor, especially in renal transplant recipients. Though GFR-estimating formulae have been relied upon, they do have their own limitations. Nevertheless, renal biomarkers such as neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C, among others, are now emerging as potentially useful indicators of GFR. We aimed to evaluate the diagnostic performance of NGAL versus cystatin C and eGFR using CKD-EPI, MDRD and cystatin C in renal transplant recipients and non-transplant CKD patients. We found a significant correlation between NGAL, serum creatinine, cystatin C and eGFR. The latter parameters were also strong predictors of serum NGAL levels. However, performance of NGAL, based on receiver operating characteristic curves, was inferior to that of the reference tests. It appears that in renal transplant recipients NGAL correlates well with cystatin C and eGFR, most strongly with cystatin-based formula. Though this suggests potential use of NGAL as a screening test, its weaker diagnostic performance raises some concern about its clinical usefulness. Larger studies are needed to explore this further.

Acute kidney injury secondary to renal large B-cell lymphoma: role of early renal biopsy.

Renal involvement in large B-cell lymphoma represents an exceptional manifestation of non-Hodgkin lymphomas. Acute kidney injury (AKI) by lymphomatous infiltration is extremely rare and so far only 19 cases have been reported in the literature. We report a 67-year-old woman who presented with AKI and was found to have large B-cell lymphoma infiltrating her kidneys. The patient was treated with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) with rituximab, and a dramatic improvement of renal function was noticed after two weeks of treatment. Her renal function completely recovered after four weeks of treatment. In conclusion, lymphomatous infiltration of kidneys can directly lead to AKI. Rapid diagnosis and treatment is essential to preserve the renal function. Renal biopsy is the gold standard for the early diagnosis of non-Hodgkin lymphoma as a cause of AKI.

Gonadal dysfunction and infertility in kidney transplant patients receiving sirolimus.

Sirolimus is an immunosupressor of the mammalian target of rapamycin inhibitors (mTOR-I) group. Recent studies have emphasized a potential impact of sirolimus on male gonadal function. We report our clinical experience with sirolimus-induced gonadal dysfunction and infertility in both male and female kidney transplant patients. Of the 170 kidney transplant patients, nine (5.3%) patients (six males and three females) were receiving sirolimus. Follow-up data for two male patients were not available. The one unmarried female patient developed amenorrhea post-transplantation and had resumption of her menstrual cycles after discontinuation of sirolimus. The remaining six married patients (four males and two females), who all had fathered or conceived children in the pre-transplantation period, developed gonadal dysfunction and infertility on average 5-12 months after transplantation. Sirolimus was discontinued in all four male patients with full recovery of the oligo/azospermia and restoration of fertility. Both married female patients developed amenorrhea post-transplantation. Sirolimus was discontinued in one female patient with resumption of her menstrual cycles. In this small population of patients treated with sirolimus, the prevalence rate of reversible gonadal dysfunction and infertility was significant in both males and females. Infertility secondary to sirolimus is under-diagnosed and should be studied further.

Low IGF-1 levels are associated with cardiovascular risk factors in haemodialysis patients.

Cardiovascular diseases (CVD) constitute a significant risk and may, in part, explain the high morbidity and mortality rates among haemodialysis (HD) patients. Several studies have implicated reduced insulin like growth factor (IGF-1) levels in the development of CVD. However, it is not clear whether IGF-1, and its relationship with other hormones such as leptin, insulin, and growth hormone (GH), as well as anthropometric variables may explain the high incidence of vascular complications in chronic kidney disease (CKD) patients. This study was designed to measure total serum IGF-1, leptin, insulin and GH levels in CKD patients and in age-matched control subjects and to elucidate the relationship between IGF-1 and GH, leptin, and insulin as well as other known aetiological risk factors for CVD including blood pressure, body mass index (BMI), and age. The study consisted of 50 CKD patients [36 M and 14 F; mean age; 41.8 +/- 10.3 years) on maintenance haemodialysis and 50 healthy control subjects (36 M and 14 F; mean age 41.6 +/- 10.2 years) matched for age and sex. None of the subject among patients and controls reported either smoking or history of diabetes mellitus. The circulating levels of IGF-1 were significantly lower (P < 0.001) in both male and female patients compared to the control subjects. Moreover, IGF-1 was strongly and inversely correlated with both systolic blood pressure (SBP) (r = -0.360; P < 0.01) and diastolic blood pressure (DBP) (r = -0.512; P < 0.001) in the CKD group, and when the two groups were combined SBP (r = -0.396; P < 0.001) and DBP (r = -0.296; P < 0.01). When adjusted for age, the correlation was more significant, however, when adjusted for BMI no significant correlation was observed between IGF-1 and blood pressure. IGF-1 was inversely correlated with age (r = -0.367; P < 0.01) and BMI (r = -0.310; P < 0.05) in the control group, but not the patient group. In controls and patients, respectively, a positive correlation between leptin and BMI (r = 0.358; P < 0.01; r = 0.640, P < 0.001) was observed. The results show that circulating levels of IGF-1 were significantly lower in CKD patients as compared to healthy normal subjects and were inversely correlated with SBP and DBP independent of age, but not BMI indicative of a strong relationship between cardiovascular risk factors and low IGF-1 levels. Although, the data do not clearly indicate low IGF-1 levels as a cause or an effect of these cardiovascular risk factors, they do point to an interesting relationship between low IGF-1 levels and increased cardiovascular risk factors among CKD patients as compared to age-matched healthy control subjects.