Association of visceral fat area with chronic kidney disease and metabolic syndrome risk in the general population: analysis using multi-frequency bioimpedance.

BACKGROUND/AIMS: Advances in bioimpedance analysis (BIA) technologies now enable visceral fat area (VFA) to be assessed using this method. The aim of this study was to evaluate the clinical relevance and usefulness of VFA as a predictor of chronic kidney disease (CKD) and metabolic syndrome (MS), using BIA. METHODS: We identified 24,791 adults who underwent voluntary routine health checkups at Yeungnam University Hospital. In total 22,480 patients were recruited into our study. Participants were divided into 3 tertiles based on their VFA: low, middle, and high tertiles. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73m(2). RESULTS: The higher tertile of VFA was associated with a higher prevalence of diabetes mellitus, hypertension, and male sex. Waist-to-hip ratio, body mass index, blood pressure, lean mass, body fat %, and fasting glucose, total cholesterol, triglyceride, GGT, AST, ALT, and uric acid levels all increased as the VFA tertile increased (P < 0.001 for all variables). The prevalence of CKD was 6.9% in the low tertile, 13.9% in the middle tertile, and 25.2% in the high tertile (P < 0.001). The prevalence of MS was 2.2% in the low tertile, 12.8% in the middle tertile, and 36.7% in the high tertile (P < 0.001). The AUROC values for VFA were higher than those for BMI and WHR. For VFA, the sensitivity and specificity for predicting CKD were 62.66% (95% CI, 61.0-64.3) and 64.22% (95% CI, 63.5-64.9), respectively, and 77.65% (95% CI, 76.3-79.0), and 68.81% (95% CI, 68.1-69.5), respectively for predicting MS. CONCLUSION: Our results demonstrated that the VFA, measured by BIA, is a simple method for predicting the risk of CKD and MS.

Paricalcitol ameliorates epithelial-to-mesenchymal transition in the peritoneal mesothelium.

BACKGROUND: The purpose of the present study was to examine the effectiveness of paricalcitol for the prevention of epithelial-to-mesenchymal transition (EMT). MATERIALS AND METHODS: Human peritoneal mesothelial cells (HPMCs) were cultured in media containing transforming growth factor ß1 (TGF-ß1) with or without paricalcitol. Forty-two male Sprague-Dawley rats were divided into three groups. In the control group, the catheter was inserted but no dialysate was infused. The peritoneal dialysis (PD) group was infused with a conventional 4.25% dialysis solution. The paricalcitol group was infused with 4.25% dialysis solution and cotreated with paricalcitol. RESULTS: Exposure of HPMCs to TGF-ß1 decreased the protein level of the epithelial cell marker and increased the expression levels of the mesenchymal markers. Cotreatment with paricalcitol increased the protein levels of the epithelial cell marker and decreased those of mesenchymal markers compared with their levels in cells treated with TGF-ß1 alone. Exposure of HPMCs to TGF-ß1 significantly increased the phosphorylation of Smad2 and Smad3. Cotreatment with paricalcitol significantly decreased the phosphorylation of Smad2 and Smad3 compared with that of cells treated with TGF-ß1 alone. After 8 weeks of experimental PD in rats, the thickness of the peritoneal membrane in the PD group was significantly increased compared with that of the control group. Cotreatment with paricalcitol decreased peritoneal thickness. CONCLUSION: The present study showed that paricalcitol attenuates the TGF-ß1-induced EMT in peritoneal mesothelial cells. We suggest that paricalcitol may preserve peritoneal mesothelial cells during PD and could thus be of value for the success of long-term PD.

Body composition measurements using bioimpedance analysis in peritoneal dialysis patients are affected by the presence of dialysate.

The presence of peritoneal dialysate when performing bioimpedance analysis may affect body composition measurements. The aim of this study was to evaluate the impact of dialysate on body composition measurements in Asians. Forty-one patients undergoing maintenance peritoneal dialysis in our hospital peritoneal dialysis unit were included in this study. Dialysate was drained from the abdomen prior to measurement, and bioimpedance analysis was performed using multi-frequency bioimpedance analysis, with each subject in a standing position (D-). Dialysate was then administered and the measurement was repeated (D+). The presence of peritoneal dialysate led to an increase in intracellular water (ICW), extracellular water (ECW), and total body water (D-: 20.33 ± 3.72 L for ICW and 13.53 ± 2.54 L for ECW; D+: 20.96 ± 3.78 L for ICW and 14.10 ± 2.59 L for ECW; P < 0.001 for both variables). Total and trunk oedema indices were higher in the presence of peritoneal dialysate. In addition, the presence of peritoneal dialysate led to an overestimation of mineral content and free fat mass (FFM) for the total body; but led to an underestimation of body fat (D-: 45.80 ± 8.26 kg for FFM and 19.30 ± 6.27 kg for body fat; D+: 47.51 ± 8.38 kg for FFM and 17.59 ± 6.47 kg for body fat; P < 0.001 for both variables). Our results demonstrate that the presence of peritoneal dialysate leads to an overestimation of FFM and an underestimation of fat mass. An empty abdomen is recommended when evaluating body composition using bioimpedance analysis.

Proteinuria as a risk factor for decline in residual renal function in non-diabetic peritoneal dialysis patients.

BACKGROUND: Preservation of residual renal function (RRF) is a major issue for patients on peritoneal dialysis (PD). Whether proteinuria is associated with a decline in RRF in patients on PD remains unclear. PATIENTS AND METHODS: We reviewed the medical records at the Yeungnam University Hospital in Korea and identified patients who started PD between June 1995 and August 2011. A total of 147 non-diabetic patients were enrolled in the study. The patients were divided into 3 groups with respect to the tertile of initial proteinuria level: Low (n = 49; <320 mg/day), Middle (n = 49; 320-822 mg/day), and High groups (n = 49; >822 mg/day). RESULTS: The mean patient age was 50.2 ± 15.0 years in the Low tertile, 50.2 ± 15.4 years in the Middle tertile, and 49.0 ± 15.1 years in the High tertile. Decline in RRF during follow-up period was greater in the High tertile than that in the other tertiles (P = 0.001). The proportion of patients with RRF >50% of baseline at 24 months after the initiation of PD was 83% in the Low tertile, 66% in the Middle tertile, and 40% in the High tertile (P < 0.001). The multivariate analysis after adjusting for initial RRF, age, gender, underlying disease of end-stage renal disease except diabetes mellitus, PD modality, use of icodextrin, PD-associated peritonitis, and tertile of the initial proteinuria level revealed that High tertile of the initial proteinuria level was associated with a decline in RRF (hazard ratios: 2.442 for the Middle tertile, P = 0.007 ; 3.713 for the Low tertile, P < 0.001). CONCLUSION: The present study demonstrates that proteinuria may be is associated with a rapid decline in RRF in non-diabetic patients on PD, although the potential role of additional factors should be further investigated in prospective studies.

Predicting residual renal function in peritoneal dialysis patients using an estimated glomerular filtration rate based on serum creatinine levels.

BACKGROUND: The aim of this study was to evaluate regression equations correcting estimated glomerular filtration rate (eGFR) and the clinical significance of the corrected eGFRs calculated using these equations. PATIENTS AND METHODS: The authors determined how well corrected eGFR values calculated using regression equations predict residual renal function (RRF). RESULTS: RRF values were correlated with all eGFR values of nonanuric patients of both genders. Peritoneal creatinine clearance values were not correlated with eGFRs in anuric patients of either gender. In males, eGFR biases ranged from -5.66 to -3.25, and in females, from -5.96 to -3.21. However, these biases decreased when eGFR values were transformed to corrected eGFR values. The area under the curve of the corrected eGFR values was acceptable for a diagnosis of RRF loss. CONCLUSION: Corrected eGFR values obtained using these methods may provide an alternative means of predicting RRF without 24-hour urine collection.

Comparison of bioimpedance analysis and dual-energy X-ray absorptiometry body composition measurements in peritoneal dialysis patients according to edema.

BACKGROUND: Changes in the difference between bioimpedance analysis (BIA) and dual-energy X-ray absorptiometry (DXA) body composition measurements according to edema is an important issue for peritoneal dialysis (PD) patients. METHODS: We reviewed the medical records of patients to identify all adults who had undergone PD and composition measurements by both BIA and DXA techniques. The aim of this study was to evaluate any change in the difference between BIA and DXA body composition measurements according to edema. RESULTS: We identified 409 patients whose body compositions were measured by both techniques one or more times, for a total of 1,109 pairs of measurements. The measurements were divided into 4 quartiles on the basis of the edema index. Significant correlations and intraclass correlations were noted between the two methods for lean mass (LM), fat mass (FM), and bone mineral content. Simple linear regression analyses using DXA measurements for the prediction of body compositions by BIA showed that non-standardized-ßs of total LM decreased as the grade of edema index increased (from 1.008 to 0.949), whereas non-standardized-ßs of total FM increased as the grade of edema index increased (from 1.034 to 1.162). Bias for total LM changed from positive to negative, and this negative bias amplified as the grade of edema index escalated (from 0.406 kg to -2.276 kg). A positive bias was observed for total FM in the 1st quartile, and this positive bias increased with an increase in the grade of edema index (from 0.594 kg to 2.863 kg). CONCLUSION: LM measured by DXA is overestimated in PD patients with edema compared to the measurements by BIA. However, FM and bone mineral content measured by BIA are is overestimated in PD patients, compared to the measurements by DXA, especially in patients with worsening edema. The difference between the two techniques grows more prominent as the grade of edema increases. A combination of two methods will allow clinicians to conduct more accurate body composition assessments for PD patients with edema.

Characteristics and clinical outcomes of hyponatraemia in peritoneal dialysis patients.

AIM: There are few reports on the incidence, aetiology, and mortality of peritoneal dialysis (PD) patients with hyponatraemia. METHODS: We identified all adults (>18-years-of-age) who received PD between May 2001 and March 2010. The patients were divided into two groups according to the presence of hyponatraemia (<135 mmol/L) during follow-up. Total body water (TBW) was obtained from bioimpedance analysis. Appropriate water gain was defined as a more than 3.6% increase of the mean TBW during normonatraemia in the same patient. Aetiologies of hyponatraemia were divided into two classes according to TBW. RESULTS: Three hundred and eighty seven patients were enrolled in this study. Ninety nine had normonatraemia and 288 developed hyponatraemia during follow-up. Among 241 episodes with simultaneous bioelectrical impedance analysis measurement, there were 71 cases with appropriate water gain and 170 cases with non-appropriate water gain. Low residual renal function and long duration of PD were associated with development of hyponatraemia by appropriate water gain. On multivariate analysis, old age (≥65-years-of-age), hypoalbuminaemia (<35 g/L), low residual renal function (<2 mL/min per 1.73(2) ) and a high comorbid condition were associated with mortality in the PD patients. The patients with intermediate and high Davies index had an odds ratio of 3.25 for development of hyponatraemia during the follow-up period (95% confidence interval, 2.025-5.215; P < 0.001). CONCLUSION: The prevalence of hyponatraemia increases along with the increased comorbidity status. The comorbidity conditions may be more important than hyponatraemia per se for predicting mortality. Additionally, the preservation of residual renal function may play a role in preventing hyponatraemia.

Limb/trunk lean mass ratio as a risk factor for mortality in peritoneal dialysis patients.

BACKGROUND: This study was performed to determine the clinical relevance of limb/trunk lean mass ratio (LTLM) in continuous ambulatory peritoneal dialysis (CAPD) patients. METHODS: This retrospective cohort study included 534 CAPD patients. Body compositions were measured using a dual-energy X-ray absorptiometry apparatus. RESULTS: In males, the sensitivity and specificity for the diagnosis of sarcopenia were 70.3% and 85.9%, respectively. Respective values in females were 62.3% and 83.8%. The initial low LTLM tertile was associated with mortality in male CAPD patients and in female CAPD patients. Among patients who maintained CAPD for a year, the maintenance of low LTLM tertile was associated with mortality. CONCLUSIONS: LTLM is associated with other lean mass indices, nutritional status, and mortality in CAPD patients. Therefore, LTLM is a novel marker that is useful for the prediction of the nutritional status and mortality in patients with CAPD.

Change in body composition in accordance with residual renal function in patients on peritoneal dialysis.

OBJECTIVES: The aim of this study is to evaluate changes in body composition in accordance with residual renal function (RRF). SUBJECTS AND METHODS: Two hundred forty-four patients with more than 1 year of follow-up were enrolled. The mean value of RRF at peritoneal dialysis (PD) initiation and 1 year after PD initiation was used as an indicator of the time-averaged RRF (TA-RRF). The patients were divided into 3 groups with respect to the tertile of the TA-RRF level: low tertile (n = 81), middle tertile (n = 82), and high tertile (n = 81). Body composition measurement was determined from dual-energy X-ray absorptiometry and bioimpedance analysis. This analysis was performed at PD initiation and 1 year after PD initiation. RESULTS: Multivariate analysis showed that the high TA-RRF tertile was associated with an increase in lean mass index. Fat mass index in all tertiles and bone mineral content index in the middle and high TA-RRF tertiles were increased, but no significant difference were observed in these changes among the 3 tertiles. The edema index decreased over the 1-year PD period. The high TA-RRF tertile was associated with a lower edema index. Although there was no statistical significance, the increase in fat mass/lean mass ratio (FM/LM) attenuated as the grade of TA-RRF tertile increased. The increase in fat mass index was similar to the trend in FM/LM. CONCLUSION: TA-RRF was associated with an increase in total lean mass and a decrease in edema index.

Changes in renal function in long-term survivors of allogeneic hematopoietic stem-cell transplantation: single-center experience.

BACKGROUND: Renal dysfunction after allogeneic hematopoietic stem cell transplantation (HSCT) has been increasingly reported. However, there are few reports on the changes of the estimated glomerular filtration rate (eGFR) in long-term survivors after allogeneic HSCT. PATIENTS AND METHODS: The medical records at Seoul St. Mary's Hospital in Korea were reviewed to identify all adult (> 18-years-of-age) patients who had undergone high-dose chemotherapy and allogeneic HSCT between January 2001 and December 2005. Among these patients, those with < 5 years of follow-up and relapse within 5 years after HSCT were excluded. 85 patients were enrolled. RESULTS: The mean follow-up was 76.0 ± 13.5 months. The eGFR recorded 3 months after HSCT was significantly decreased compared with the eGFR recorded before HSCT. Subsequently, early decreased eGFR was maintained during the 60 months after HSCT. Multivariate analysis showed that acute kidney injury (AKI) during HSCT, hypertension (HTN) and eGFR before HSCT was differently associated with changes in eGFR. The eGFR in patients who had AKI decreased significantly at 3 months after HSCT. After 3 months, the eGFR recovered to reach a lower level than in patients without AKI. The level was maintained during the 60 months after HSCT. The eGFR in patients who had low eGFR before HSCT (< 90 ml/min) decreased significantly at 3 months after HSCT, which was also maintained during the 60 months after HSCT. The eGFR in patients who had HTN also decreased significantly at 3 months after HSCT. By contrast, the eGFR decreased consistently and slowly from 3 to 60 months. CONCLUSION: AKI and low baseline eGFR are associated with early renal dysfunction in patients after HSCT, but are not closely associated with long-term decline in eGFR. In contrast, eGFR in patients with HTN continuously decrease after 3 months of HSCT. Therefore, HTN seems to play a major role in the long-term decline in eGFR. These findings suggest that eGFR at 3 months after HSCT should be monitored closely for all patients who have undergone HSCT. Additionally, long-term follow-up of renal function is needed to prevent further renal damage for patients with HTN.

Low-calcium dialysate as a risk factor for decline in bone mineral density in peritoneal dialysis patients.

OBJECTIVE: Few studies have linked changes in bone mineral density (BMD) in peritoneal dialysis (PD) patients to the calcium concentration in peritoneal dialysate. MATERIAL AND METHODS: In total, 236 incident patients who underwent an annual BMD determination for 2 years were enrolled. The patients were divided into two groups: the standard calcium dialysate (SCD) group (n = 190; 1.75 mmol/l) and the low-calcium dialysate (LCD) group (n = 46; 1.25 mmol/l). RESULTS: There were no significant differences between the baseline demographics of the two groups, such as age, diabetes, calcium, phosphorus, alkaline phosphatase (ALP), intact parathyroid hormone (i-PTH) levels or variables related to BMD. Univariate and multivariate analyses [adjusted for age, gender and time-averaged 25(OH)-vitamin D] determined that the LCD group had higher time-averaged i-PTH and ALP and a greater decrease in bone mineral content, lumbar spine BMD, subtotal BMD and total BMD compared to the SCD group. CONCLUSION: LCD is associated with a more rapid decline in BMD, higher i-PTH and higher ALP in PD patients. It is suggested that LCD be avoided for PD patients at risk of osteoporosis and hyperparathyroidism.

Catheter revision for the treatment of intractable exit site infection/tunnel infection in peritoneal dialysis patients: a single centre experience.

AIM: Catheter-related infection is a major cause of catheter loss in peritoneal dialysis (PD). We evaluated the effect of catheter revision on the treatment of intractable exit site infection (ESI)/tunnel infection (TI) in PD patients who required catheter removal. METHODS: We reviewed the medical records of 764 continuous ambulatory peritoneal dialysis (CAPD) patients from May 1995 to April 2011 at our hospital. One hundred and twenty six patients had more than one occurrence of ESI. Catheter revision was performed to treat intractable ESI/TI. Incidence of ESI, causative organisms and the outcomes of catheter revision were analyzed. RESULTS: The total PD duration of all patients was 32,581 months. Three hundred and twelve ESI episodes occurred in 126 patients and the incidence of ESI was 1/104 patient-months (0.12/patient-year). The most common causative organism was methicillin-sensitive Staphylococcus aureus (MSSA) (98 episodes), followed by Pseudomonas aeruginosa (63 episodes) and methicillin-resistant S. aureus (MRSA) (28 episodes). Among these, catheter revision was required due to intractable ESI/TI in 36 patients. The most common causative organism was MSSA (14 episodes) followed by P. aeruginosa (10 episodes) and MRSA (six episodes) in catheter revision cases. The outcomes of catheter revision were as follows: ESI relapsed in 11 patients (30.6%) after catheter revision. Among them, five patients were treated with antibiotic treatment, two patients required secondary catheter revision, four patients required catheter removal due to ESI/TI accompanying peritonitis. The catheter survival rate after catheter revision was 89.7% in one year. There were no statistical differences in the rates of ESI relapse after catheter revision between ESI caused by P. aeruginosa (5/10, 50%) and ESI caused by S.aureus (6/21, 28.6%). CONCLUSION: Catheter revision may be an alternative treatment option to treat intractable ESI/TI before catheter removal is considered in PD patients.

Blind peritoneal catheter placement with a Tenckhoff trocar by nephrologists: a single-center experience.

AIM: Blind peritoneal dialysis (PD) catheter instrumentation with a Tenckhoff trocar is performed without direct visualization of the peritoneum. This method requires the least equipment, it is safe and it can be performed mainly by nephrologists. We report here on our long-term experience with this method as performed by nephrologists. METHODS: We reviewed the medical records at Yeungnam University Hospital in Korea and identified all the patients who had undergone blind PD catheter instrumentation with a Tenckhoff trocar by nephrologists. Four hundred and three patients were enrolled. RESULTS: Early complications occurred in 7.7% (four patients with pericatheter bleeding, one patient with pleural leakage, two patients with migration, two patients with omental wrapping, three patients with exit site/tunnel infection and 19 patients with peritonitis). The late mechanical complications included eight cases of hernia, three cases of catheter extrusion, five cases of leakage, four cases of migration and five cases of omental wrapping. Exit site/tunnel infection and peritonitis occurred at a rate of 0.067 and 0.40 episodes/year, respectively. The intervention free survival rate was 84.5% at one year and 63.3% at 5 years. The catheter survival rate was 96.5% at one year and 83.6% at 5 years. CONCLUSION: This study provides evidence that blind PD catheter placement with a Tenckhoff trocar requires the least equipments, and it is easy to perform. Therefore, if the general anesthesia is impossible or equipment, such as fluoroscopy and laparoscopy, were not available, this method may be an alternative choice for PD catheter placement.

Impact of heavy proteinuria on clinical outcomes in patients on incident peritoneal dialysis.

BACKGROUND: There are few reports on the nutritional status changes and residual renal function (RRF) according to proteinuria levels in patients on peritoneal dialysis (PD). METHODS: A total of 388 patients on PD were enrolled. The patients were divided into 3 groups with respect to initial proteinuria: the A (n = 119; <500 mg/day), B (n = 218; 500-3,500 mg/day), and C groups (n = 51; >3,500 mg/day). RESULTS: The patients with higher proteinuria levels had a higher incidence of male sex, diabetes mellitus, and icodextrin use than those with lower proteinuria levels. Although initial peritoneal albumin loss in C group was lower than that detected in the other groups, no significant difference was observed in peritoneal albumin loss among the 3 groups at the end of follow-up period. At the time of PD initiation, the Geriatric nutritional risk index (GNRI) was lower in the C group than in the other 2 groups. However, at the end of the follow-up period, there was no significant difference in GNRI between the 3 groups. The GNRI increased, and the proteinuria level or RRF decreased more in the C group than in the other 2 groups. There were no significant differences in lean mass index or fat mass index change from the time of PD initiation to the end of the follow-up period. However, fat mass index and nPNA showed greater increases in the C group. The multivariate analysis revealed that proteinuria was negatively correlated with GNRI at the time of PD initiation and at the end of the follow-up period. The initial RRF and proteinuria were negatively correlated with the RRF decline during the follow-up. CONCLUSION: The attenuation of the nephrotic proteinuria, along with the RRF decline, was associated with the improvement of the malnutrition.

Onodera's prognostic nutritional index as a risk factor for mortality in peritoneal dialysis patients.

The aim of this study was to evaluate the clinical relevance and usefulness of the Onodera's prognostic nutritional index (OPNI) as a prognostic and nutritional indicator in peritoneal dialysis (PD) patients. Patients were divided into 3 groups based on the initial OPNI score: group A (n = 186, < 40), group B (n = 150, 40-45), and group C (n = 186, > 45). Group A was associated with a higher grade according to the Davies risk index than the other groups. Serum creatinine and albumin levels, total lymphocyte count, and fat mass increased with an increase in OPNI. According to the edema index, the correlation coefficient for OPNI was -0.284 and for serum albumin was -0.322. Similarly, according to the C-reactive protein (CRP), the correlation coefficient for OPNI was -0.117 and for serum albumin was -0.169. Multivariate analysis adjusted for age, Davies risk index, CRP, and edema index revealed that the hazard ratios for low OPNI, serum albumin, and CRP were 1.672 (P = 0.003), 1.308 (P = 0.130), and 1.349 (P = 0.083), respectively. Our results demonstrate that the OPNI is a simple method that can be used for predicting the nutritional status and clinical outcome in PD patients.

Risk factors for mortality in stable peritoneal dialysis patients.

BACKGROUND: The mortality rates of end-stage renal disease patients have significantly declined over the past decade. However, there are few reports on the risk factors for mortality in stable peritoneal dialysis (PD) patients who survive for a considerable time. PATIENTS AND METHODS: We reviewed the medical records and identified all adult patients who received PD between April 2001 and March 2009 in our institution. The total cohort was 550 patients. Among these patients, 383 patients were enrolled as stable PD patients. RESULTS: The cumulative survival of the stable PD patients was 91.6% at 3 years and 78.7% at 5 years. On univariate analysis, old age (≥65 years of age), hypoalbuminemia (<35 g/L), log C-reactive protein (CRP) (≥0.84), phosphorus (<1.13 mmol/L), statin, icodextrin, and the Davies index were associated with mortality for all PD patients. Old age, hypoalbuminemia, log CRP, phosphorus, the residual renal function (RRF) (≤4 mL/min/1.73 m2) at 24 months, renin-angiotensin system blockade, icodextrin, and the Davies index were associated with mortality for the stable PD patients. Multivariate analysis showed that, among the variables, age, log CRP, phosphorus, initial RRF, and the Davies index were associated with mortality for all PD patients. In stable PD patients, age, log CRP, phosphorus, RRF at 24 months, and the Davies index were associated with mortality. CONCLUSION: Initial high RRF combined with the RRF preservation, maintenance of proper phosphorus, control of inflammation, and proper management of comorbidities may help to improve the survival of PD patients including stable PD patients.

Effect of icodextrin dialysis solution on body weight and fat accumulation over time in CAPD patients.

BACKGROUND: The purpose of this study was to analyse the changes of body composition and the effects of icodextrin dialysis solution over time on peritoneal dialysis (PD) in continuous ambulatory peritoneal dialysis (CAPD) patients. METHODS: Among 183 incident patients, 75 patients finished a complete 36-month protocol. Clinical indices including daily glucose absorption and body composition, by bioelectrical impedance analysis (BIA), were measured in both groups (icodextrin group: 36 patients, non-icodextrin group: 39 patients) at the 1st (baseline), 12th, 24th and 36th months. RESULTS: There were significant increases in body weight and fat mass during the 36 months after initiation of CAPD. It was found that 78% of 3 years of weight gain occurred during the first year and 88% of weight gain at the end of the first year was fat mass gain. The icodextrin group showed a significantly lower percent of fat mass during the first 36 months (P < 0.05) and also less changes in body weight, fat mass, percent (%) fat mass, visceral fat area and waist/hip ratio at 1, 2 and 3 years than the non-icodextrin group. There were no significant changes in total body water (TBW), extra cellular fluid (ECF), oedema index and lean body mass (LBM) through comparable daily and ultrafiltration volume (UFV) between the two groups during the initial 3 years. Factors associated with the higher percent of fat mass gain over time on peritoneal dialysis were age, diabetes, gender (female) and non-icodextrin group (all, P < 0.01, generalized estimating equation). CONCLUSION: The application of icodextrin solution may be a better option to alleviate excessive fat gain over time for patients on PD.

The association between the vascular endothelial growth factor-to-cancer antigen 125 ratio in peritoneal dialysis effluent and the epithelial-to-mesenchymal transition in continuous ambulatory peritoneal dialysis.

We examined peritoneal growth factors, mesothelial mass, and epithelial-to-mesenchymal transition (EMT) in response to peritoneal exposure to peritoneal dialysate with standard and low concentrations of glucose degradation products (GDPs). We randomized 56 incident continuous ambulatory peritoneal dialysis (CAPD) patients to receive either low-GDP (30 patients) or high-GDP (standard) peritoneal dialysis (PD) solution (26 patients). The effects of the PD solutions on EMT and peritoneal growth factors in overnight dialysate effluent were compared at 1, 6, and 12 months. Assessment of EMT was performed after human peritoneal mesothelial cells (HPMCs) were cultured from overnight effluent. The low-GDP solution group showed significantly higher dialysate levels of cancer antigen 125 (CA125), fibronectin, transforming growth factor beta(TGFbeta)-induced gene product (betaig-h3), and interleukin-6 (IL-6), but the rate of EMT was significantly lower in the low-GDP solution group during the initial 12 months of CAPD treatment. After adjusting peritoneal growth factors for dialysate CA125 concentration, the low-GDP solution group showed significantly lower ratios of fibronectin/CA125, betaig-h3/CA125, IL-6/CA125, TGFbeta/CA125, and vascular endothelial growth factor (VEGF)/CA125 than did patients in the high-GDP (standard) solution group. Factors associated with higher EMT were the type of solution (high in GDPs), the mass of HPMCs (low CA125), and higher VEGF/CA125. Adjustment of dialysate VEGF for effluent CA125 revealed a significant association with EMT. It suggests that fibroblastoid transition from HPMCs could be affected by the intraperitoneal VEGF per unit mass of HPMCs.

The effect of low glucose degradation product dialysis solution on epithelial-to-mesenchymal transition in continuous ambulatory peritoneal dialysis patients.

BACKGROUND: Human peritoneal mesothelial cells (HPMCs) undergo a transition from an epithelial phenotype to a mesenchymal phenotype (EMT) during peritoneal dialysis (PD). That transition may be directly related to failure of peritoneal membrane function. OBJECTIVE: In a randomized prospective controlled study, we investigated the effect of low glucose degradation product (GDP) dialysis solution on the transition of HPMCs. METHODS: Among new continuous ambulatory PD patients, 60 patients completed a 12-month protocol (low-GDP solution group, n = 32; high-GDP solution group, n = 28). At the 1st, 6th, and 12th months, HPMCs drained from overnight effluent were cultured on T25. When they had nearly reached confluence, cell scores were measured blindly by the same person (score 1 = cobblestone-shaped HPMCs, score 2 = mixed, score 3 = fibroblast dominant). Cell scores and clinical indices, including peritoneal markers, were compared between the low-GDP and high-GDP groups at the 1st, 6th, and 12th months. The factors associated with EMT were analyzed with generalized estimating equations using STATA 7.0 (STATA Corp., College Station, Texas, USA). In addition, vimentin and cytokeratin 8/18 stains were used to verify EMT in cultured cells and peritoneal specimens in some patients. RESULTS: (1) The low-GOP group showed higher dialysate cancer antigen 125 levels from the 1st to 12th months (55.4 +/- 24.8 vs 8.8 +/- 1.7, 56.7 +/- 28.1 vs 22.1 +/- 11.3, and 54.2 +/- 28.2 vs 24.6 +/- 16.5 U/mL, at the 1st, 6th, and 12th months, respectively; all p = 0.000). (2) The low-GOP group showed lower cell scores at the 1st, 6th, and 12th months (1.22, 1.22, and 1.56 vs 1.61, 1.75, and 2.14; p < 0.05, p < 0.01, and p < 0.01, respectively). (3) At the 12th month, the number of fibroblast-dominant cultures (score 3) was significantly lower in the low-GOP group [4/32 (12.5%) patients vs 14/28 (50%), p < 0.05]. (4) Both cobblestone-shaped HPMCs and fibroblastoid cells were positively stained with cytokeratin and vimentin. (5) There were many cytokeratin- and vimentin-positive cells in the submesothelial area in the peritoneal biopsy specimens. (6) The consistent factor associated with EMT was only high-GOP solution (60 patients, n = 178, beta coefficient 0.312, p = 0.000; 46 patients, n = 137, beta coef: 0.228, p = 0.000) and not numbers of peritonitis episodes, duration of angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker medication, or diabetes. CONCLUSION: Low-GDP solution showed beneficial effects such as rapid remesothelialization and less EMT in the peritoneum with time on PD.

Association between low-grade albuminuria and hearing impairment in a non-diabetic Korean population: The Korea National Health and Nutrition Examination Survey (2011-2013).

INTRODUCTION: The objective of the present study was to examine the association between low-grade albuminuria and hearing impairment in the non-diabetic population. MATERIALS AND METHODS: Data from the Korean National Health and Nutrition Examination Survey 2011-2013 were used in the analyses. Participants were excluded from this study if they were younger than 19 years old, or had urine albumin/creatinine ratio (UACR) ≥ 30 mg/g or diabetes mellitus. There were 10,608 participants included in this study. The participants were divided into three groups according to their UACR tertiles. RESULTS: There were 1560; 1561; and 1552 male and 1982; 1975; and 1978, female participants in the low, middle, and high tertile groups, respectively. The results indicated the association between low-grade albuminuria and the numbers of metabolic syndrome (MetS) components or Framingham risk score, and the presence of MetS or the proportions of participants at high cardiovascular risk. Univariate and multivariate linear regression analyses demonstrated an association between the UACR and average hearing threshold (AHT) that was observed in both sexes. Multivariate analyses showed that mean AHTs in the low, middle, and high tertile groups were, respectively, 16.127 dB, 17.139 dB, and 18.604 dB for men, and 14.842 dB, 15.100 dB, and 16.353 dB, respectively, for women. Low-frequency, mid-frequency, and high-frequency hearing thresholds according to UACR tertiles showed similar trends. In both sexes, multivariate logistic regression analyses revealed that participants in the low and middle tertile groups had a decreased risk for hearing loss compared to participants in the high tertile group. CONCLUSION: Low-grade albuminuria was associated with hearing impairment in the non-diabetic participants of this study.